AB0737 FAST TRACK PATHWAY: A GIANT STEP FOR THE DIAGNOSIS AND MANAGEMENT OF GIANT CELL ARTERITIS

Abstract

BackgroundGiant cell arteritis (GCA), a medium and large vessel vasculitis remains a formidable disease. Through feed-forward loops and a multitude of vascular complications, GCA impacts seriously negatively on both the patient’s vision as well as life. In 2018, Darent Valley Hospital published its GCA management pathway [1] and launched a fast track GCA clinic in 2019. This included clinical assessment along with US examination in the rheumatology outpatients’ clinic. The pathway enabled direct access to both general practitioners in primary care as well as health care professionals in secondary care to this service. Education sessions for both the primary and secondary care teams were carried out to inform them of the referral criteria and the service pathway.ObjectivesTo evaluate the impact of implementing the GCA-fast track pathway on prompt diagnosis and treatment of GCA.MethodsRetrospective cohort analysis of patients referred to the Fast Track GCA clinic. A cohort of patients with new suspected diagnosis of GCA along with acute flare ups of diagnosed GCA cases were referred to the clinic according to a set up referral criteria. All the patients referred to the clinic were offered an appointment within 24-hours and had blood tests for inflammatory markers and basic rheumatology blood profile done prior to their assessment. Diagnosis of GCA was made based on clinical examination, laboratory results and US assessment [2]. Presence of ‘halo’ sign, which is a non-compressible hypo-echoic ring around the artery lumen reflecting inflammation of the vessel wall was considered as a positive US finding. Steroid therapy was commenced on the same day of the diagnosis. If steroid infusion is indicated, the patient is referred to the AEC/ AMU to have the steroid infusion on the same day. Outcomes of management were assessed by GCA-patient reported outcomes as well as US assessment. The service was audited twice.ResultsDuring the evaluation period, 56 patients were referred to the Fast track GCA clinic. Age range 57-87 years old. 78.6% of these patients were females. 85.7% (48/56) of these patients were offered an appointment and assessed within one working day (24-hours), whereas the remaining 14.3% (8/56) were reviewed within 24-72 hours. All the patients (100%) had US examination of the temporal artery within the targeted time of maximum 72-hours from the referral date and less than 2-weeks of presenting with the temporal headache. Six patients were diagnosed as non-GCA, 5-patients migraine, 1-patient trigeminal neuralgia, 2-patients with large vessel vasculitis, 3-patients with PMR and 2-patients had flare of their previous PMR. 37-patients (66.1%) were diagnosed with GCA. No biopsies were performed. 9-patients (24.3%) required IV steroid infusion, whereas 28-patients (75.7%) started oral steroids. None of the patients included in the study suffered GCA related sight loss. No hospital admissions were required for these patients. There was significant improvement in the GCA patient reported outcomes in response to therapy, US measures as well as the inflammatory markers.ConclusionThe developed Fast Track GCA clinic has significantly facilitated early and prompt diagnosis as well as management of GCA. Majority of the patients were reviewed within 24-hours with immediate initiation of steroid therapy. The fast-track referral pathway, combined with GP education, resulted in a significant reduction of incidences of permanent sight loss attributed to GCA (which would have resulted in loss of independence and mobility which subsequent increase health care use) and has proven to be a cost-effective practice as number of admitted patients was reduced.