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Prednisone must be taken at a dosage level that maintains control of inflammation. Several indicators of GCA control are C-rP, sed rate, RBC (red blood cells), Hgb (hemoglobin), Hct (Hematocrit), Alkaline Phosphatase and Platelets at normal levels. These parameters are monitored monthly by blood tests since GCA activity can change. Prednisone may need to be adjusted upwards or downwards.
Failure to maintain control can result in what has been termed "smoldering inflammation" – meaning inflammation is present in arteries to some extent. Any inflammation can damage arteries and the organs those arteries nourish.
One specific area that is vulnerable to smoldering inflammation is the aorta. Aneurysms can form in GCA weakened aorta artery walls and rupture to cause death if not identified and corrected. A significant number of these have been reported, sometimes between five to seven years after patients were thought to have gone into remission. Aortic aneurysms aren’t only the result of smoldering inflammation. The aorta is a common site for initial presentation of GCA, similar to the temporal artery and optic nerve. Some people are found at autopsy to have had an aortic aneurysm caused by GCA inflammation that ruptured – their death was the initial indication of GCA.
The amount of inflammation to qualify for "smoldering" inflammation isn’t defined. We can assume that it is any inflammation that occurs because prednisone dosing is inadequate. With that definition Pearl suffered the following conditions due to smoldering inflammation – with adequate prednisone these might have been avoided:
I am suspicious that her shoulder joint problems may have been influenced by uncontrolled inflammation. They had the symptoms initially of uncontrolled PMR – bursitis and rotator cuff tendonitis. Synovitis, the medical term for inflammation of a synovial membrane (joint lining), was diagnosed by several orthopedists, affecting her shoulder joints and most recently – her knee joint. On-going degradation of the shoulder joints resulted in complete rotator cuff tears. These were sustained during physical therapy to improve the freedom of motion in both joints. Studies even before 1980 described the evidence in many patients of PMR in synovial fluid of the shoulders, knees and sterno-clavicular joints several years after diagnosis. Two weeks before her death Pearl was seen by an orthopedist for persistent right knee inflammation which had been present for several months.
Patients in treatment and those in remission must remain vigilant for signs of smoldering GCA in any medium or larger artery. C-rP and sed rate should be measured as needed to monitor this.