An older patient with unilateral vision loss, headaches, fatigue, proximal weakness, and an elevated ESR. What is the recommended treatment?

• A. Methotrexate
• B. Prednisone
• C. Cyclophosphamide
• D. Azathioprine

Answer: (B)

This presentation points to giant cell arteritis, a vasculitis in adults over 50 that can threaten vision. The priority is to prevent irreversible blindness from ischemia of the optic nerve, so treatment must start immediately with high-dose glucocorticoids. The best choice is prednisone at a high dose (about 40–60 mg daily). If there’s acute vision loss, many clinicians begin with intravenous methylprednisolone (1 g daily for 3 days) followed by oral prednisone and a gradual taper. Temporal artery biopsy should be pursued to confirm the diagnosis, but treatment should not wait for biopsy results.

The other agents listed are not first-line for suspected giant cell arteritis with vision risk; they’re typically used as steroid-sparing options or for different vasculitides, not to provide the urgent vessel-wide anti-inflammatory effect needed here.