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One medical journal article was especially informative for GCA management. It was authored by Dr. Hayreh and associates involved in research at the Ophthalmology department of the University of Iowa. Some unusual conclusions based on their 27-year study of 145 GCA patients were: 21% of patients have occult (symptomless) GCA – their diagnosis came after having only a vision event; all GCA patients will have a positive biopsy if the procedure is done thoroughly; blindness is preventable with adequate dosing of prednisone except for possible vision loss within the first five days of treatment; only 8% of GCA patients achieve remission – others require from 1 to 16 mg/day for many years; depressed hemoglobin and hematocrit were described as GCA flare indicators; treatment was done using C-rP and sed rate only – not relying on symptoms; and normal levels of C-rP and sed rate were defined as those levels achieved with high doses of prednisone in the first few months of treatment. Extracts from his journal article can be found on a University of Iowa Ophthalmology website.
While all of these unique observations were valuable for Pearl the last one proved to be most informative. While CrP wasn’t measured the first year the sed rate was observed to have a normal level of < 10 mm/hr in the first 2 months. Values of normal sed rate varied from < 15 (defined by the Rheumatologist) to < 42 (calculated using a formula based on age and sex by an authoritative source). In managing Pearl’s GCA the Rheumatologist started with < 15 but violated his definition often in striving to minimize the steroid dose. At what level he would decide to take action with a prednisone increase was unpredictable. This demonstrated an undisciplined practice which I thought was uncharacteristic of him. Had we managed Pearl’s illness with the < 10 value of normal for sed rate she might have had significantly improved quality of life.
Another significant recommendation in the paper was the use of CrP and sed rate only, rather than relying on symptoms to manage the prednisone dosing. Pearl lost total vision momentarily on 12/10/04 – 5 years into her illness. Her C-rP had been 1.2 (slightly elevated) and sed rate was 32 (elevated) a month before. She was taking 8 mg/day of prednisone at the time of the blood test and 7.5 mg when vision was temporarily lost. This was one of those occasions when the Rheumatologist violated his self-imposed guideline and didn’t increase prednisone when sed rate exceeded his sed rate normal of <15 mm/hr. This was the scenario Dr. Hayreh’s paper was trying to avoid by strictly adhering to dosing according to C-rP and sed rate. Waiting for Pearl to have the symptom of vision loss was almost a disaster. Fortunately it wasn’t permanent and high prednisone prevented permanent damage to her good eye at that point. However, the smoldering illness took its toll in her shoulders soon after the vision loss.