The tricky part of giant cell arteritis (GCA) is the need for rapid evaluation, given the high risk of rapid vision loss and the importance of getting appropriate diagnostic tests, such as a temporal artery biopsy, soon after starting treatment. Unfortunately, there are not a lot of outpatient programs that handle urgent issues related to GCA—and within 48 hours.
To fulfill this need, the Penn Giant Cell Arteritis Fast-Track Program, which launched in January 2020, was created for patients with suspected or relapsing GCA who need rapid evaluation. The program provides rapid multi-disciplinary evaluation, initiates appropriate therapy promptly, and facilitates innovative research in GCA.
“Patients with high-risk features will be seen by a rheumatologist within 48 hours, as well as other appropriate specialists,” said Rennie Rhee, MD, MS, Assistant Professor in the Department of Medicine/ Rheumatology at the Hospital of the University of Pennsylvania, Philadelphia. “Temporal artery biopsies will be done within one week; treatment may be initiated if suspicion for GCA is high and there is concern for visual impairment.”
The fast-track program, led by the Penn Vasculitis Center within Rheumatology, is located within outpatient practices at the Perelman Center for Advanced Medicine and the Penn Medicine University City locations in Philadelphia. Dr. Rhee had worked for several months to develop a pathway and collaborators for the program. The rheumatology team includes: Shubhasree Banerjee, MD, Assistant Professor of Clinical Medicine, Penn Medicine; Peter Merkel, MD, MPH, Chief, Division of Rheumatology, Penn Medicine; and Naomi Amudala, CRNP, MSN, Penn Medicine.
All members of the rheumatology team specialize in vasculitis and have been involved in clinical research in GCA. “We have a neuro-ophthalmologist with extensive experience in evaluating and managing patients with GCA,” said Dr. Rhee, “and a team of vascular surgeons who can see patients quickly to perform temporal artery biopsies in a timely fashion.”
The program provides a rigorous and standardized approach to processing and interpreting biopsy specimens, which will bereviewed by Franz Fogt, MD, PhD, MBA, Professor of Pathology and Laboratory Medicine at the Hospital of the University of Pennsylvania. Dr. Fogt specializes in ophthalmic pathology (including temporal artery biopsies). A neurologist is on board as well—Katherine Hamilton, MD, Assistant Professor of Clinical Neurology, Penn Medicine—and she specializes in headaches for patients who have them as a primary symptom but do not have GCA.
There will be a dedicated phone line for providers to call and discuss potential GCA cases with one of the program’s vasculitis specialists. “If appropriate, we will then schedule the patient within 48 hours and coordinate expedited care with other specialists when indicated. For providers within Penn, we also have a separate consult order, which facilitates the triaging process,” Dr. Rhee said. For now, providers can call the Penn Division of Rheumatology for scheduling: 215-662-4333.
Note that only providers can call and refer patients to the program. “This is to ensure appropriate work-up is done beforehand, in case the patient needs to be seen by other specialists and does not have GCA,” Dr. Rhee said.
Early diagnosis and prompt treatment of GCA is vital. “Vision loss is the most feared complication of GCA and it can occur incredibly fast—sometimes within a few hours from the onset of the first visual symptoms. There’s a very small window in which initiation of therapy can prevent a patient from going blind in one or both eyes,” Dr. Rhee explained. “At the same time, we need to be careful that we don’t unnecessarily expose patients to high doses of steroids, such as prednisone, which are associated with many side effects.”
The program will treat any symptom that is part of GCA (eg, polymyalgia rheumatica) and, if needed, partner with primary care providers as well. Some patients may need to see several specialists routinely, depending on their manifestations (eg, ophthalmology). The benefit of seeing a rheumatologist is that there is a growing number of steroid-sparing options for GCA, including the first-ever FDA-approved drug, tocilizumab, for GCA, Dr. Rhee said.
There are now multiple ongoing clinical trials of novel therapies for GCA, and patients who are interested can also learn more about these opportunities through the fast-track program.
Author: Nina Silberstein
This article originally appeared in the March/April 2020 VF Newsletter.