Introduction

The diagnosis and treatment of primary vasculitides are integral components of rheumatological care. Giant cell arteritis (GCA) represents the most common primary vasculitis. Delayed initiation of therapy often leads to severe complications such as vision loss. Following the introduction of fast-track clinics (FTC), the proportion of permanent blindness in newly diagnosed GCA cases decreased from 19–37% to 2–13% [3, 5, 6, 10]. These recommendations aim to clarify the concept of “FTC” for healthcare provision.

Current recommendations and care status

Musculoskeletal ultrasound has been a component of rheumatology training in Germany for over 35 years. Ultrasound expertise and quality equipment are widely available in German rheumatology. The new German regulations for rheumatology training, effective since 2022, are the first worldwide to include vascular ultrasound for acute diagnosis of vasculitis [7].

Diagnosis of GCA should involve clinical history and examination supplemented by a confirmatory test. Temporal artery biopsy (TAB) with histology or imaging modalities such as ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), or 18F-fluorodeoxyglucose positron emission tomography (PET) are suitable for confirmation according to current guidelines [9]. New EULAR recommendations advocate for ultrasound of the temporal and axillary arteries as the preferred imaging modality, based on robust evidence supporting its high sensitivity and specificity, widespread availability, low cost, and feasibility in clinical practice [1].

Mostly, patients with suspected GCA already receive prompt rheumatology appointments. Additionally, various centers in Germany offer FTCs with immediate or 1–2 working day appointments, where expert-led structured clinical history, clinical examination, laboratory diagnostics, and specialized vascular ultrasound are conducted. These experts, usually rheumatologists, perform clinical examination and ultrasound concurrently, ensuring accurate diagnosis confirmation or exclusion. Alternatively, collaborations with angiologists (vascular medicine specialists) exist. If diagnosis remains unclear, an additional imaging modality or a TAB is performed. A PubMed search on 18 February 2024 using “giant cell arteritis” and “fast-track clinic” identified 50 publications since 2014, yet no national or international consensus statement defining FTCs precisely.

Recommendations for FTC requirements

A team of nine rheumatologists and one angiologist from Germany, experienced in GCA diagnosis and treatment, developed recommendations for defining FTCs (Table 1). This process included a web conference, followed by extensive email communication and another web conference with open voting.

Table 1 Recommendations for requirements of a GCA fast-track clinic
Full size table

Discussion

Ad 1: Contact for suspected GCA cases should be straightforward and rapid for referring physicians, potentially facilitated by the on-duty hospital physician even on weekends, or via phone with qualified personnel during the workweek. If capacity allows, patients with polymyalgia rheumatica (PMR) may also be seen, as subclinical GCA can occur in this population. Recently, it has been recommended that all patients with suspected or recently diagnosed PMR should be considered for specialist evaluation [4].

Ad 2: In cases of high suspicion for GCA, glucocorticoid therapy should be initiated prior to confirmation, with diagnostic evaluation ideally within the first 3 days to ensure diagnostic accuracy. In case of prolonged therapy, efforts should still be made to confirm the diagnosis. Organizational problems must not delay treatment initiation.

Ad 3–6: Expertise in GCA and ultrasound is essential for accurate diagnosis. A high-quality examination is expected with experience exceeding 300 ultrasound examinations [8]. If performed by a trainee, confirmation by a specialist is necessary. The Rheumaakademie (German rheumatology academy) regularly offers DEGUM (German Society for Ultrasound in Medicine)-certified courses on clinical aspects and ultrasound in GCA and PMR.

Ad 7–8: Detailed technical and operational guidelines can be found, among others, in the updated EULAR recommendations [2]. These recommendations should extend to FTC organization, with standardization instructions being particularly important for on-call services.

Ad 9: Collaborations exist in larger hospitals, within the framework of Ambulatory Specialized Care (ASV), or other outpatient networks. PET-CT examinations are reimbursed only in the ASV sector and mostly for privately insured individuals in German outpatient care. TAB is almost exclusively offered in inpatient settings in Germany.

These recommendations provide initial guidance on FTC prerequisites. They can serve as a basis for an implementation process for certification, potentially supported by the German Society for Rheumatology (DGRh).

Practice implications

  • Fast-track clinics for rapid diagnosis of giant cell arteritis (GCA) should be easily accessible and offer appointments within 24 h on weekdays.

  • Requirements include medical specialist expertise in GCA and specific ultrasound examinations, adherence to standardization instructions, and adequate ultrasound technology.

  • Collaborative partners, including for ophthalmological and neurological examinations, temporal artery biopsy, and other imaging modalities, should be available.