from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import datetime

doc = Document()

# ── Page margins
for section in doc.sections:
    section.top_margin    = Inches(1.0)
    section.bottom_margin = Inches(1.0)
    section.left_margin   = Inches(1.2)
    section.right_margin  = Inches(1.2)

# ── Default Normal style
normal = doc.styles["Normal"]
normal.font.name = "Arial"
normal.font.size = Pt(11)

# ── Heading helper colours
RED      = RGBColor(0xC0, 0x00, 0x00)
DARK_RED = RGBColor(0x7B, 0x00, 0x00)
NAVY     = RGBColor(0x1F, 0x39, 0x64)
TEAL     = RGBColor(0x00, 0x70, 0x70)
ORANGE   = RGBColor(0xBF, 0x60, 0x00)
BLACK    = RGBColor(0x00, 0x00, 0x00)
WHITE    = RGBColor(0xFF, 0xFF, 0xFF)
LIGHT_GREY = RGBColor(0xF2, 0xF2, 0xF2)

def set_cell_bg(cell, hex_color_str):
    """Set table cell background colour via XML shading."""
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement("w:shd")
    shd.set(qn("w:val"), "clear")
    shd.set(qn("w:color"), "auto")
    shd.set(qn("w:fill"), hex_color_str)
    tcPr.append(shd)

def add_heading(doc, text, level=1, color=NAVY):
    h = doc.add_heading(text, level=level)
    h.alignment = WD_ALIGN_PARAGRAPH.LEFT
    for run in h.runs:
        run.font.color.rgb = color
        run.font.name = "Arial"
    return h

def add_para(doc, text, bold=False, color=BLACK, size=11, left_indent=0):
    p = doc.add_paragraph()
    p.paragraph_format.left_indent = Inches(left_indent)
    p.paragraph_format.space_after = Pt(4)
    run = p.add_run(text)
    run.bold = bold
    run.font.color.rgb = color
    run.font.name = "Arial"
    run.font.size = Pt(size)
    return p

def add_bullet(doc, text, level=0, bold_prefix=None):
    p = doc.add_paragraph(style="List Bullet")
    p.paragraph_format.left_indent = Inches(0.3 + level * 0.25)
    p.paragraph_format.space_after = Pt(3)
    if bold_prefix:
        run = p.add_run(bold_prefix)
        run.bold = True
        run.font.name = "Arial"
        run.font.size = Pt(11)
        rest = p.add_run(text)
        rest.font.name = "Arial"
        rest.font.size = Pt(11)
    else:
        run = p.add_run(text)
        run.font.name = "Arial"
        run.font.size = Pt(11)

def add_alert_box(doc, label, text, bg="FF0000", fg="FFFFFF"):
    """Single-row coloured alert banner."""
    tbl = doc.add_table(rows=1, cols=1)
    tbl.style = "Table Grid"
    cell = tbl.cell(0, 0)
    set_cell_bg(cell, bg)
    p = cell.paragraphs[0]
    p.alignment = WD_ALIGN_PARAGRAPH.LEFT
    r1 = p.add_run(f"{label}  ")
    r1.bold = True
    r1.font.name = "Arial"
    r1.font.size = Pt(11)
    r1.font.color.rgb = RGBColor(int(fg[0:2],16), int(fg[2:4],16), int(fg[4:6],16))
    r2 = p.add_run(text)
    r2.font.name = "Arial"
    r2.font.size = Pt(11)
    r2.font.color.rgb = RGBColor(int(fg[0:2],16), int(fg[2:4],16), int(fg[4:6],16))
    doc.add_paragraph()

# ════════════════════════════════════════════════
# COVER / TITLE
# ════════════════════════════════════════════════
title_p = doc.add_paragraph()
title_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = title_p.add_run("Giant Cell Arteritis (GCA)")
r.bold = True; r.font.size = Pt(24); r.font.color.rgb = DARK_RED; r.font.name = "Arial"

sub_p = doc.add_paragraph()
sub_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
r2 = sub_p.add_run("Management and Treatment Protocol in Autoimmune Patients")
r2.bold = True; r2.font.size = Pt(16); r2.font.color.rgb = NAVY; r2.font.name = "Arial"

doc.add_paragraph()
info_p = doc.add_paragraph()
info_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
r3 = info_p.add_run(f"Version 1.0  |  Issued: {datetime.date.today().strftime('%B %Y')}  |  Department of Rheumatology")
r3.font.size = Pt(10); r3.font.color.rgb = RGBColor(0x80,0x80,0x80); r3.font.name = "Arial"

doc.add_paragraph()
doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 1 – SCOPE AND PURPOSE
# ════════════════════════════════════════════════
add_heading(doc, "1.  Scope and Purpose", 1, NAVY)
add_para(doc,
    "This protocol provides a standardised framework for the diagnosis, immediate management, "
    "pharmacological treatment, monitoring, and follow-up of Giant Cell Arteritis (GCA) — "
    "also known as temporal arteritis — with particular reference to patients who have an "
    "existing autoimmune background (e.g., ANA positivity, undifferentiated connective tissue disease, "
    "Sjögren's syndrome, or prior inflammatory arthritis).",
    size=11)
add_para(doc,
    "GCA is the most common primary systemic vasculitis in adults. Irreversible visual loss remains "
    "its most feared complication; prompt recognition and treatment are mandatory.",
    bold=False, size=11)

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 2 – BACKGROUND
# ════════════════════════════════════════════════
add_heading(doc, "2.  Background and Pathophysiology", 1, NAVY)
add_para(doc,
    "GCA is a granulomatous vasculitis primarily affecting medium- and large-sized arteries "
    "— particularly the extracranial branches of the carotid artery (temporal, ophthalmic, "
    "posterior ciliary arteries) and the thoracic aorta. Inflammatory infiltrates of CD4+ T-cells, "
    "macrophages, and multinucleated giant cells cause arterial wall damage, intimal hyperplasia, "
    "and luminal narrowing.",
    size=11)

doc.add_paragraph()
add_para(doc, "Key epidemiological facts:", bold=True, size=11)
add_bullet(doc, "Occurs almost exclusively in patients aged >50 years (peak incidence 70-80 years).")
add_bullet(doc, "Women affected 2-3x more frequently than men.")
add_bullet(doc, "Strong association with HLA-DR4 haplotype.")
add_bullet(doc, "18x increased risk of thoracic aortic aneurysm vs. general population (Harrison's, 2025).")
add_bullet(doc, "In autoimmune patients: ANA positivity, prior undifferentiated CTD, or Sjögren's syndrome "
           "may overlap; vigilance is required as serological markers from the background disease can "
           "obscure interpretation of inflammatory markers.")

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 3 – DIAGNOSIS
# ════════════════════════════════════════════════
add_heading(doc, "3.  Diagnostic Criteria and Work-up", 1, NAVY)
add_heading(doc, "3.1  ACR/EULAR 2022 Classification Criteria", 2, TEAL)
add_para(doc,
    "The updated 2022 ACR/EULAR classification requires age ≥50 years at symptom onset. "
    "The following weighted criteria are then applied (total ≥6 = GCA classification):",
    size=11)

# Criteria table
tbl = doc.add_table(rows=9, cols=3)
tbl.style = "Table Grid"
headers = ["Criterion", "Threshold", "Score"]
for i, h in enumerate(headers):
    cell = tbl.cell(0, i)
    set_cell_bg(cell, "1F3964")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10)
    r.font.color.rgb = WHITE

rows_data = [
    ("New temporal headache", "New onset or new type of localised head pain", "+2"),
    ("Jaw or tongue claudication", "Pain/fatigue in jaw muscles on chewing", "+2"),
    ("Sudden visual loss", "Acute or subacute monocular visual loss", "+3"),
    ("Scalp tenderness", "Tenderness on palpation of scalp", "+2"),
    ("Abnormal temporal artery exam", "Tenderness or decreased pulsation", "+2"),
    ("ESR ≥50 mm/hr or CRP ≥10 mg/L", "Peak acute-phase reactant elevation", "+3"),
    ("Positive TAB or halo sign on US", "Biopsy vasculitis or ultrasound halo", "+5"),
    ("Morning stiffness in shoulders/neck", "PMR-like symptom overlap", "+2"),
]
for i, (c1, c2, c3) in enumerate(rows_data):
    row = tbl.rows[i+1]
    bg = "F2F2F2" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate([c1, c2, c3]):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)
        if j == 2:
            r.bold = True; r.font.color.rgb = RED

doc.add_paragraph()

add_heading(doc, "3.2  Mandatory Immediate Work-up", 2, TEAL)
add_para(doc, "Initiate ALL of the following before or simultaneously with empirical treatment:", size=11)

workup_tbl = doc.add_table(rows=8, cols=3)
workup_tbl.style = "Table Grid"
for i, h in enumerate(["Investigation", "Rationale", "Urgency"]):
    cell = workup_tbl.cell(0, i)
    set_cell_bg(cell, "007070")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = WHITE

wu_rows = [
    ("ESR + CRP + Platelet count", "Elevated in >95% of active GCA; guide taper", "STAT"),
    ("FBC, LFTs, renal function", "Baseline before steroids; detect haematological malignancy", "Same day"),
    ("Temporal artery ultrasound (halo sign)", "Non-invasive; included in 2022 ACR criteria", "Within 24 hrs"),
    ("Temporal artery biopsy (TAB)", "Gold standard; do NOT delay treatment for result", "Within 1 week"),
    ("Ophthalmology referral", "Visual field, fundus, RAPD; prevent irreversible loss", "SAME DAY if visual Sx"),
    ("ANA panel, Anti-dsDNA, complement", "Characterise autoimmune background; rule out SLE flare", "Same day"),
    ("Anti-Ro/SSA, Anti-La/SSB", "Rule out Sjögren's overlap", "Same day"),
]
for i, (c1, c2, c3) in enumerate(wu_rows):
    row = workup_tbl.rows[i+1]
    bg = "F2F2F2" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate([c1, c2, c3]):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)
        if j == 2 and "SAME" in txt:
            r.bold = True; r.font.color.rgb = RED
        elif j == 2 and "STAT" in txt:
            r.bold = True; r.font.color.rgb = ORANGE

doc.add_paragraph()

# ALERT BOX
add_alert_box(doc,
    "CRITICAL:",
    "Do NOT wait for biopsy results before starting corticosteroids when clinical suspicion is high. "
    "Histological changes persist for up to 2 weeks after steroid initiation.",
    bg="C00000", fg="FFFFFF")

# ════════════════════════════════════════════════
# SECTION 4 – TREATMENT
# ════════════════════════════════════════════════
add_heading(doc, "4.  Pharmacological Treatment Protocol", 1, NAVY)

add_heading(doc, "4.1  First-Line: Glucocorticoids", 2, TEAL)
add_para(doc,
    "Corticosteroids remain the cornerstone of GCA treatment. Both GCA and its symptoms are "
    "highly responsive to glucocorticoid therapy. (Goldman-Cecil Medicine, 2024)",
    size=11)

doc.add_paragraph()
# Treatment table
tx_tbl = doc.add_table(rows=5, cols=3)
tx_tbl.style = "Table Grid"
for i, h in enumerate(["Clinical Scenario", "Agent & Dose", "Duration / Notes"]):
    cell = tx_tbl.cell(0, i)
    set_cell_bg(cell, "1F3964")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = WHITE

tx_rows = [
    ("Standard GCA (no visual symptoms)",
     "Prednisone 40-60 mg/day orally in divided doses",
     "Maintain for ~1 month; then taper by 5-10 mg every 7-10 days"),
    ("GCA with visual loss or amaurosis fugax",
     "IV Methylprednisolone 500 mg-1 g/day for 3 days, then oral prednisone 60 mg/day",
     "Intravenous pulse to protect remaining vision; follow with oral taper"),
    ("GCA with high glucocorticoid toxicity risk",
     "Prednisone 40-60 mg + Tocilizumab 162 mg SC weekly",
     "Superior sustained remission at 12 months (GIACTA trial); allows faster taper"),
    ("Polymyalgia rheumatica co-existing with GCA",
     "Prednisone 15-20 mg/day (PMR component)",
     "GCA dose takes precedence; do not under-treat"),
]
for i, (c1, c2, c3) in enumerate(tx_rows):
    row = tx_tbl.rows[i+1]
    bg = "FFF2CC" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate([c1, c2, c3]):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)

doc.add_paragraph()

add_heading(doc, "4.2  Steroid Taper Protocol", 2, TEAL)
add_para(doc,
    "Symptom recurrence during prednisone tapering occurs in 60-85% of GCA patients. "
    "Taper MUST be guided by clinical response, NOT ESR/CRP alone. (Harrison's 2025)",
    size=11)

add_bullet(doc, "Weeks 1-4: Maintain starting dose (40-60 mg/day). ESR, CRP, Hb, and platelets should normalise.", bold_prefix="Phase 1 – Induction:  ")
add_bullet(doc, "Reduce by 5-10 mg every 7-10 days until reaching 20 mg/day.", bold_prefix="Phase 2 – Initial taper:  ")
add_bullet(doc, "Reduce by 2.5 mg every 2-4 weeks until reaching 10 mg/day.", bold_prefix="Phase 3 – Slow taper:  ")
add_bullet(doc, "Reduce by 1 mg every 4-8 weeks. Total duration usually ≥2 years.", bold_prefix="Phase 4 – Maintenance taper:  ")
add_bullet(doc, "Alternate-day regimens are NOT recommended in GCA (higher failure rate).", bold_prefix="Important:  ")

doc.add_paragraph()

add_heading(doc, "4.3  Steroid-Sparing / Adjunct Therapy", 2, TEAL)

adj_tbl = doc.add_table(rows=5, cols=4)
adj_tbl.style = "Table Grid"
for i, h in enumerate(["Agent", "Dose", "Indication", "Evidence Level"]):
    cell = adj_tbl.cell(0, i)
    set_cell_bg(cell, "007070")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = WHITE

adj_rows = [
    ("Tocilizumab (IL-6 receptor inhibitor)", "162 mg SC weekly OR 6 mg/kg IV q4 weeks",
     "FDA-approved for GCA; first-line steroid-sparer; reduce cumulative steroid dose",
     "RCT (GIACTA) — High"),
    ("Sarilumab (IL-6 inhibitor)", "200 mg SC q2 weeks",
     "Approved for refractory PMR; off-label GCA consideration",
     "RCT — Moderate"),
    ("Methotrexate", "7.5-15 mg weekly (+ folate)",
     "Second-line steroid-sparer; conflicting RCT results; use if tocilizumab intolerant",
     "RCT — Low-Moderate"),
    ("Low-dose Aspirin", "75-100 mg daily",
     "Reduce ischaemic complications; adjunctive only — marginal evidence",
     "Observational — Low"),
]
for i, row_data in enumerate(adj_rows):
    row = adj_tbl.rows[i+1]
    bg = "F2F2F2" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate(row_data):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)

doc.add_paragraph()

add_heading(doc, "4.4  Special Considerations in Autoimmune Patients", 2, TEAL)
add_para(doc,
    "Patients with a background autoimmune disease (ANA+, prior UCTD, Sjögren's, SLE) require "
    "additional vigilance during GCA treatment:",
    size=11)
add_bullet(doc, "Background ANA/anti-dsDNA serology may remain elevated independently of GCA activity — use clinical symptoms and ESR/CRP trends together.", bold_prefix="Serological interpretation:  ")
add_bullet(doc, "Prior DMARD use (e.g., hydroxychloroquine, methotrexate) does NOT confer protection against GCA; do not reduce vigilance.", bold_prefix="Prior DMARD history:  ")
add_bullet(doc, "Tocilizumab may suppress ESR/CRP even in the presence of ongoing vascular inflammation — rely on imaging (PET-CT or MRA) when markers are suppressed.", bold_prefix="Tocilizumab masking effect:  ")
add_bullet(doc, "Screen for drug interactions between tocilizumab and existing DMARDs (particularly methotrexate — monitoring of LFTs/FBC required).", bold_prefix="Drug interactions:  ")
add_bullet(doc, "Patients on long-term hydroxychloroquine for UCTD: continue this therapy; it does not interfere with GCA management.", bold_prefix="Hydroxychloroquine:  ")

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 5 – MONITORING
# ════════════════════════════════════════════════
add_heading(doc, "5.  Monitoring Protocol", 1, NAVY)
add_heading(doc, "5.1  Monitoring Schedule", 2, TEAL)

mon_tbl = doc.add_table(rows=7, cols=3)
mon_tbl.style = "Table Grid"
for i, h in enumerate(["Time Point", "Investigations", "Clinical Assessment"]):
    cell = mon_tbl.cell(0, i)
    set_cell_bg(cell, "1F3964")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = WHITE

mon_rows = [
    ("Week 1-2", "ESR, CRP, FBC, glucose", "Symptom response; visual acuity check; blood pressure"),
    ("Month 1", "ESR, CRP, HbA1c, LFTs, bone profile", "Steroid side-effect screen; ophthalmology review if visual Sx"),
    ("Months 2-6 (during taper)", "ESR, CRP monthly; FBC, LFTs q6-8 weeks", "Relapse symptoms; weight, BP, glucose; bone density baseline (DEXA)"),
    ("Months 6-12", "ESR, CRP every 6-8 weeks", "Taper progress; screen for aortic complications"),
    ("Year 1-2", "Annual ESR, CRP, DEXA; ANA recheck", "Monitor for evolving CTD in autoimmune patients; osteoporosis"),
    ("If on Tocilizumab", "FBC, LFTs q4-8 weeks; lipid profile q6 months", "Monitor for neutropenia, hepatotoxicity, hyperlipidaemia"),
]
for i, row_data in enumerate(mon_rows):
    row = mon_tbl.rows[i+1]
    bg = "F2F2F2" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate(row_data):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)

doc.add_paragraph()

add_heading(doc, "5.2  Interpreting Inflammatory Markers During Taper", 2, TEAL)
add_para(doc,
    "ESR and CRP are useful but imperfect markers. Minor rises during taper do not automatically "
    "indicate relapse — particularly if the patient is asymptomatic. (Harrison's 2025)",
    size=11)
add_bullet(doc, "Symptomatic relapse + rising ESR/CRP → increase prednisone by 5-10 mg to the last effective dose.")
add_bullet(doc, "Asymptomatic ESR/CRP rise → continue taper with caution; recheck in 2-4 weeks; rule out infection.")
add_bullet(doc, "In tocilizumab-treated patients: ESR/CRP are suppressed regardless of disease activity. Rely on PET-CT or MRA for imaging-based disease assessment in refractory or suspected relapsing cases.")

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 6 – COMPLICATION PREVENTION
# ════════════════════════════════════════════════
add_heading(doc, "6.  Complication Prevention and Supportive Measures", 1, NAVY)

add_para(doc, "Glucocorticoid toxicity occurs in 35-65% of GCA patients. (Goldman-Cecil, 2024)", size=11, bold=True)
doc.add_paragraph()

comp_tbl = doc.add_table(rows=7, cols=3)
comp_tbl.style = "Table Grid"
for i, h in enumerate(["Complication", "Prevention Strategy", "Threshold"]):
    cell = comp_tbl.cell(0, i)
    set_cell_bg(cell, "BF6000")
    p = cell.paragraphs[0]
    r = p.add_run(h)
    r.bold = True; r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = WHITE

comp_rows = [
    ("Osteoporosis", "Calcium 1000-1200 mg/day + Vitamin D 800 IU/day; bisphosphonate (alendronate/risedronate) if DEXA T-score <-1.5", "Start at initiation of steroids"),
    ("Peptic ulcer disease", "PPI (omeprazole 20 mg/day) particularly if on aspirin", "If aspirin co-prescribed or GI risk factors"),
    ("Hyperglycaemia", "Monitor fasting glucose weekly initially; intensify diabetes management if needed", "Fasting glucose >7.0 mmol/L"),
    ("Hypertension", "BP monitoring; ACE inhibitor or ARB if indicated", "BP >140/90 mmHg"),
    ("Infections", "Pneumocystis prophylaxis (co-trimoxazole) if on >20 mg/day prednisone >1 month; annual influenza + pneumococcal vaccine", "Ongoing high-dose steroids"),
    ("Aortic aneurysm", "Annual thoracic aorta imaging (CT or MRA) in long-standing GCA", "Patients with GCA for >2 years"),
]
for i, row_data in enumerate(comp_rows):
    row = comp_tbl.rows[i+1]
    bg = "FFF2CC" if i % 2 == 0 else "FFFFFF"
    for j, txt in enumerate(row_data):
        cell = row.cells[j]
        set_cell_bg(cell, bg)
        p = cell.paragraphs[0]
        r = p.add_run(txt)
        r.font.name = "Arial"; r.font.size = Pt(10)

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 7 – RELAPSE MANAGEMENT
# ════════════════════════════════════════════════
add_heading(doc, "7.  Relapse Recognition and Management", 1, NAVY)
add_para(doc,
    "Relapse occurs in 60-85% of GCA patients during steroid tapering. Distinguish true "
    "relapse from steroid dependence and background autoimmune disease flare.",
    size=11)

add_heading(doc, "7.1  Relapse Criteria", 2, TEAL)
add_bullet(doc, "Return or worsening of GCA symptoms (new headache, jaw claudication, visual symptoms, scalp tenderness).")
add_bullet(doc, "Rise in ESR ≥30 mm/hr above nadir OR CRP ≥2x upper limit of normal.")
add_bullet(doc, "New ischaemic event (vision loss, stroke) attributable to GCA.")

add_heading(doc, "7.2  Relapse Treatment", 2, TEAL)
add_bullet(doc, "Minor relapse (symptoms only, no visual threat): increase to the last effective prednisone dose.", bold_prefix="Minor relapse:  ")
add_bullet(doc, "Major relapse (new visual symptoms): IV methylprednisolone 500 mg-1 g/day for 3 days → re-escalate oral prednisone 60 mg/day.", bold_prefix="Major relapse:  ")
add_bullet(doc, "Recurrent relapses: add or escalate tocilizumab; consider methotrexate if tocilizumab not tolerated.", bold_prefix="Refractory GCA:  ")

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 8 – PATIENT EDUCATION
# ════════════════════════════════════════════════
add_heading(doc, "8.  Patient Education and Red-Flag Counselling", 1, NAVY)
add_para(doc, "All GCA patients must be educated to report the following IMMEDIATELY:", bold=True, color=RED, size=11)
add_bullet(doc, "Any sudden or new visual disturbance (blurring, double vision, transient vision loss).")
add_bullet(doc, "Worsening jaw pain on eating.")
add_bullet(doc, "New severe headache.")
add_bullet(doc, "Scalp tenderness or scalp ulceration.")
add_bullet(doc, "Arm pain on exertion (large-vessel GCA).")

doc.add_paragraph()
add_para(doc, "General steroid education:", bold=True, size=11)
add_bullet(doc, "Never stop steroids abruptly — risk of adrenal insufficiency.")
add_bullet(doc, "Carry a steroid alert card.")
add_bullet(doc, "Report any infection promptly — immune suppression risk.")
add_bullet(doc, "Weight-bearing exercise and calcium-rich diet to support bone health.")

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 9 – FLOWCHART SUMMARY
# ════════════════════════════════════════════════
add_heading(doc, "9.  Algorithmic Summary", 1, NAVY)

algo_steps = [
    ("STEP 1", "Clinical suspicion of GCA (headache + jaw claudication + periorbital swelling + autoimmune background)", "C00000", "FFFFFF"),
    ("STEP 2", "STAT ESR, CRP, FBC → Temporal artery ultrasound within 24 hrs → Ophthalmology same day if visual symptoms", "BF6000", "FFFFFF"),
    ("STEP 3", "Start Prednisone 40-60 mg/day IMMEDIATELY — do not wait for biopsy results", "C00000", "FFFFFF"),
    ("STEP 4", "Temporal artery biopsy within 1 week (histological confirmation)", "1F3964", "FFFFFF"),
    ("STEP 5", "Assess tocilizumab candidacy: high steroid toxicity risk, recurrent relapse, or severe disease", "007070", "FFFFFF"),
    ("STEP 6", "Steroid taper protocol (Sections 4.2); monitor ESR/CRP monthly during taper", "1F3964", "FFFFFF"),
    ("STEP 7", "Complication prevention: bone protection, PPI, glucose, BP, infection prophylaxis (Section 6)", "007070", "FFFFFF"),
    ("STEP 8", "Annual imaging of thoracic aorta after year 1; ongoing monitoring for evolving CTD in autoimmune patients", "BF6000", "FFFFFF"),
]
for step, text, bg, fg in algo_steps:
    tbl = doc.add_table(rows=1, cols=2)
    tbl.style = "Table Grid"
    # Step label
    c1 = tbl.cell(0, 0)
    set_cell_bg(c1, bg)
    c1.width = Inches(1.2)
    p1 = c1.paragraphs[0]
    p1.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r1 = p1.add_run(step)
    r1.bold = True; r1.font.name = "Arial"; r1.font.size = Pt(11)
    r1.font.color.rgb = RGBColor(int(fg[0:2],16), int(fg[2:4],16), int(fg[4:6],16))
    # Content
    c2 = tbl.cell(0, 1)
    set_cell_bg(c2, "FAFAFA")
    p2 = c2.paragraphs[0]
    r2 = p2.add_run(text)
    r2.font.name = "Arial"; r2.font.size = Pt(10)
    doc.add_paragraph().paragraph_format.space_after = Pt(2)

doc.add_paragraph()

# ════════════════════════════════════════════════
# SECTION 10 – REFERENCES
# ════════════════════════════════════════════════
add_heading(doc, "10.  References and Evidence Base", 1, NAVY)
refs = [
    "Firestein & Kelley's Textbook of Rheumatology (11th ed., 2023). Chapter 89: Giant Cell Arteritis and Polymyalgia Rheumatica. Elsevier.",
    "Harrison's Principles of Internal Medicine (22nd ed., 2025). Chapter: Giant Cell Arteritis and Polymyalgia Rheumatica. McGraw-Hill.",
    "Goldman-Cecil Medicine (27th ed., 2024). Chapter 250: Giant Cell Arteritis and Polymyalgia Rheumatica. Elsevier.",
    "Kanski's Clinical Ophthalmology (10th ed., 2024). Chapter: Giant Cell Arteritis — Ocular Manifestations. Elsevier.",
    "Stone JH et al. (2017). Trial of Tocilizumab in Giant-Cell Arteritis (GiACTA). N Engl J Med, 377:317-328. (PMID: 28745999)",
    "ACR/EULAR 2022 Classification Criteria for Giant Cell Arteritis. Arthritis & Rheumatology, 2022.",
    "Bradley and Daroff's Neurology in Clinical Practice (8th ed., 2022). Chapter: Giant Cell Arteritis — Neurological Aspects. Elsevier.",
]
for i, ref in enumerate(refs):
    p = doc.add_paragraph()
    p.paragraph_format.left_indent = Inches(0.25)
    p.paragraph_format.space_after = Pt(4)
    r = p.add_run(f"{i+1}.  {ref}")
    r.font.name = "Arial"; r.font.size = Pt(10); r.font.color.rgb = RGBColor(0x40,0x40,0x40)

doc.add_paragraph()

# ════════════════════════════════════════════════
# FOOTER NOTE
# ════════════════════════════════════════════════
footer_p = doc.add_paragraph()
footer_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
rf = footer_p.add_run(
    "This protocol is for clinical guidance only. Individual patient management decisions must be made by a qualified clinician. "
    "Review annually or when new guidelines are published.")
rf.italic = True; rf.font.size = Pt(9); rf.font.name = "Arial"
rf.font.color.rgb = RGBColor(0x80, 0x80, 0x80)

# ── Save
output_path = "/tmp/workspace/gca-protocol/GCA_Management_Protocol.docx"
doc.save(output_path)
print(f"Saved: {output_path}")