Pharmacists Can Educate Older Patients About Blindness Due to Giant Cell Arteritis
Giant cell arteritis is the most common form of systemic vasculitis in adults, yet it often goes undiagnosed until its most common complication—acute loss of vision and permanent blindness—sends them to the emergency department. This frightening and serious event can be avoided with early treatment, but first symptoms must be recognized. It’s a task accomplished with patient education. Pharmacists who take the time to talk with older patients about a few key symptoms can help them prevent blindness due to giant cell arteritis.
Prevalence and Prognosis of Giant Cell Arteritis
Giant cell arteritis (GCA) develops in people aged 50 and older. As a result, it often goes undiagnosed because its initial symptoms are generic and easy to confuse with the gamut of chronic health conditions found in elderly patients. Unrecognized GCA is a significant health concern because permanent visual loss occurs in as many as 15 to 20 percent of patients.1
Here’s a rundown of its epidemiology:
- Incidence may be as high as 27 cases per 100,000 people aged 50 or older.2
- Average annual incidence is 17.8 cases per 100,000 in those aged 50 or older.
- Prevalence of people with active or remitted GCA is about 278 cases per 100,000 (aged 50 or older).3
- People of white European ancestry are most likely to develop GCA.
- Women are affected more than men.
You may hear GCA referred to as arteritis cranialis, Horton disease, or even simply granulomatous arteritis, which accurately describes the presentation of this systemic autoimmune disease. GCA is characterized by granulomatous inflammation of large and medium-sized arteries. It typically affects the superficial temporal arteries, but it’s also commonly found in the ophthalmic, occipital, vertebral, proximal vertebral, and posterior ciliary arteries. In some cases, inflammation may involve the aorta, carotid, subclavian and iliac arteries.
The overall prognosis is excellent for patients who get treated at an early stage, but the clinical reality isn’t so rosy:
- Average treatment lasts 2 years.
- Some patients require treatment for 5 years or longer.
- Morbidity from steroid therapy is often worse than the underlying disease.
- Patients often go through cycles of remission and recurrences.
Common Symptoms May Not Foreshadow Vision Loss
Patients may experience blurred vision in the early stages of GCA, but since this is an age-related disease, a mild change may not raise concern. Even if the patient seeks help for vision changes, they’ll go to an eye doctor who may not screen for the other signs that would hint at GCA. Patients may have any or all of the following symptoms:
- Headache – usually in the temples
- Pain, ache and/or stiffness in the shoulders and hips
- Pain in the jaw while chewing (jaw claudication) – patient may eat less and lose weight
- Fever – usually low grade
- Scalp tenderness – it may hurt to comb hair
- Dry cough
- Throat or tongue pain
- Pain in the arms or legs during exercise
It’s important to know that GCA can be confused with polymyalgia rheumatica when the primary symptoms are stiffness and pain in the neck, shoulders and hips, intermittent low-grade fever, and weight loss. The two diseases are unrelated yet often occur together; about half of patients with GCA also have polymyalgia rheumatica, while 16 to 21 percent of those with polymyalgia rheumatica develop GCA.
When GCA goes untreated, inflammation and blockage of blood vessels that supply the eye ultimately affect vision. It’s typical for vision-related symptoms to be acute, appearing as sudden and severe vision loss that’s usually discovered when the patient wakes in the morning. At first one eye is affected, with visual acuity less than 20/200, then involvement of the other eye develops in a few days to weeks. Patients may also experience double vision or eye pain.
Doctors who suspect GCA may test sedimentation rate and C-reactive protein, but the gold standard—the only way to confirm a diagnosis—is to perform a biopsy of the temporal artery. However, treatment should not wait for biopsy results; it should be initiated as soon as GCA is suspected because any degree of vision loss is permanent.
Monitor Treatment for Adherence and Adverse Effects
Pharmacists can help screen for GCA in all of their older patients. During medication reviews or when you dispense other medications, ask if they’re experiencing pain in the jaw while eating, have aching hips or shoulders, headaches or blurry vision. While you’re at it, stay on the lookout for drug-induced small-vessel vasculitis.
For patients who have been diagnosed with GCA, it’s vital to connect every time you refill a prescription. Take a few minutes to assess the following:
- Adverse effects – Prednisone is the treatment of choice, with an initial dose of 40 to 60 milligrams daily. Considering the high dose and the fact that treatment typically lasts one to two years, patient education and ongoing monitoring for adverse effects is essential.
- Adherence – Ask if they’re taking medications as prescribed—remind them that their vision is at risk and that they may develop other serious complications like aneurysms if they skip doses. If they’re not adhering to the regimen, troubleshoot to find out why, then collaborate with their physician to find a solution.
- Assess for recurrences – Relapses are common in GCA patients, so patients need to be closely monitored and reminded to call their physician at the first sign of symptoms. About 64 percent have a flare-up once during the first year of treatment, while 36 percent relapse two or more times. Patients are also at risk for recurring symptoms when prednisone is tapered down to a lower maintenance dose.
Pharmacists Can Help Prevent Blindness Due to Giant Cell Arteritis
Pharmacists form the cornerstone of health care because they have the opportunity to interact with patients more frequently than other clinicians. Talk with older patients as you dispense medications for other chronic conditions, using that opportunity to teach them about symptoms of giant cell arteritis. Your efforts may help them avoid the devastating impact of blindness.
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- “Review of Giant Cell Arteritis,” November 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314573/ ↩
- “Giant Cell Arteritis (Temporal Arteritis),” November 2016, http://emedicine.medscape.com/article/332483-overview ↩
- “Giant Cell Arteritis (Temporal Arteritis),” September 2012, http://www.vasculitisfoundation.org/education/forms/giant-cell-arteritis/ ↩