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Vinicki JP, Gut O, Maliandi MDR, Velasco Zamora JL, Linarez M, Cusa MA, Got J, Spinetto MA, Estevez AJ, Brigante A, Curti AC, Costi AC, Cavallasca J. Risk Factors for Relapse and/or Prolonged Glucocorticoid Therapy in Polymyalgia Rheumatica: Multicenter Study in 185 Patients. J Clin Rheumatol 2024; 30:e34-e38. [PMID: 37185203 DOI: 10.1097/rhu.0000000000001969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND In polymyalgia rheumatica (PMR) relapses and long-term GC dependency are common. We assessed risk factors for higher relapse rate and/or prolonged glucocorticoid therapy in PMR patients. METHODS A multicenter and observational study (chart review) of PMR patients seen between 2006 and 2021 who had at least a 3-month follow-up period after starting GCs was performed. Results were expressed as median and interquartile range 25th-75th or mean ± standard deviation for numerical variables and percentage for categorical ones. Relapse versus nonrelapse groups were compared using Cox proportional analysis. Hazards ratios (HRs) with 95% confidence intervals (CIs) are reported. In all cases, a p value <0.05 was considered to indicate statistical significance. RESULTS We included 185 patients (69.1% female). The median follow-up time was 17.1 months (interquartile range, 6.8-34.7). Incidence of relapses was 1.2 per 100 persons/month. In univariate analysis, PMR patients with a previous history of dyslipidemia had a lower risk of relapse (HR, 0.55; 95% CI, 0.33-0.94; p = 0.03); high-dose GC (HR, 2.35; 95% CI, 1.42-3.87; p = 0.001) and faster GC dose reduction had higher risk of relapse (HR, 3.04; 95% CI, 1.77-5.21; p = 0.001). In multivariate analysis, a previous history of dyslipidemia had a lower risk of relapse (HR, 0.54; 95% CI, 0.32-0.92; p = 0.023), and high dose of GC (HR, 2.46; 95% CI, 1.49-4.08; p = 0.001) remained the only risk factors for relapse. CONCLUSIONS Lower doses of corticosteroids and a slow rate of reduction are critical to avoid relapse in PMR. Risk factors for higher relapse rate rely on therapy more than clinical characteristics of the patients at the time of diagnosis of PMR.
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Affiliation(s)
| | | | | | | | | | | | - Julio Got
- Unidad de Reumatología, Instituto Médico Humanitas, Chaco
| | | | | | | | | | | | - Javier Cavallasca
- Sección Reumatología, Hospital José Bernardo Iturraspe, Santa Fe, Argentina
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Perricone C, Cafaro G, Fiumicelli E, Bursi R, Bogdanos D, Riccucci I, Gerli R, Bartoloni E. Predictors of complete 24-month remission and flare in patients with polymyalgia rheumatica. Clin Exp Med 2023; 23:3391-3397. [PMID: 36566303 DOI: 10.1007/s10238-022-00976-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/08/2022] [Indexed: 12/25/2022]
Abstract
To date, few papers investigated the predictive factors of sustained 24-month remission and of flare in patients with polymyalgia rheumatica (PMR). We retrospectively evaluated clinical charts from PMR patients. Patients were evaluated at baseline, at 1 month, 3 months and subsequently at 6, 12 and 24 months. We analyzed the differences between patients who achieved remission within 6 months of diagnosis, those who achieved remission at 24 months, and patients who did not. Among 137 patients, 57 (41.6%) achieved remission at 6 months and complete remission at 24 months was achieved by 104 patients (75.9%). The erythrocyte sedimentation rate at baseline was higher in patients who did not achieve remission than in patients who achieved it (p = 0.012). Female patients were less likely to achieve complete remission (45/68, 66.2% vs. 59/69, 85.5%, p = 0.01) compared to males. Fifty-four patients (39.4%) experienced at least one flare. Patients who did not achieve sustained complete remission suffered a flare more often (22/39 vs. 32/98, p = 0.01) and earlier than patients who did (10.33 ± 7.89 months vs. 13.64 ± 6.97 months, p = 0.011). Multivariate analysis confirmed that female sex (RR = 3.2, 95% CI 1.3-7.9) and higher baseline prednisone dosage (RR = 1.1, 95% CI 1.007-1.109) were negative independent predictors of complete remission at 24 months. A significant percentage of patients with PMR requires prolonged steroid treatment and may experience flares at 24 months of follow-up. Female sex and higher baseline prednisone dosage are negative independent predictors of complete remission at 24 months.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Fiumicelli
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Dimitrios Bogdanos
- Internal Medicine and Autoimmune Diseases, Department Internal Medicine, University of Thessaly, Larissa, Greece
| | - Ilenia Riccucci
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
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Floris A, Piga M, Chessa E, Congia M, Erre GL, Angioni MM, Mathieu A, Cauli A. Long-term glucocorticoid treatment and high relapse rate remain unresolved issues in the real-life management of polymyalgia rheumatica: a systematic literature review and meta-analysis. Clin Rheumatol 2021; 41:19-31. [PMID: 34415462 PMCID: PMC8724087 DOI: 10.1007/s10067-021-05819-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/19/2021] [Accepted: 06/13/2021] [Indexed: 12/04/2022]
Abstract
A systematic review and meta-analysis were conducted, according to the PRISMA methodology, to summarize current evidence on the prevalence and predictors of long-term glucocorticoid (GC) treatment and disease relapses in the real-life management of polymyalgia rheumatica (PMR). Out of 5442 retrieved studies, 21 were eligible for meta-analysis and 24 for qualitative analysis. The pooled proportions of patients still taking GCs at 1, 2, and 5 years were respectively 77% (95%CI 71–83%), 51% (95%CI 41–61%), and 25% (95CI% 15–36%). No significant difference was recorded by distinguishing study cohorts recruited before and after the issue of the international recommendations in 2010. The pooled proportion of patients experiencing at least one relapse at 1 year from treatment initiation was 43% (95%CI 29–56%). Female gender, acute-phase reactants levels, peripheral arthritis, starting GCs dosage, and tapering speed were the most frequently investigated potential predictors of prolonged GC treatment and relapse, but with inconsistent results. Only a few studies and with conflicting results evaluated the potential role of early treatment with methotrexate in reducing the GC exposure and the risk of relapse in PMR. This study showed that a high rate of prolonged GC treatment is still recorded in the management of PMR. The relapse rate, even remarkable, can only partially explain the long-term GC treatment, suggesting that other and not yet identified factors may be involved. Additional research is needed to profile patients with a higher risk of long-term GC treatment and relapse and identify more effective steroid-sparing strategies.
Key Points: • High rate of long-term glucocorticoid (GC) treatment is recorded in polymyalgia rheumatica (PMR), being 77%, 51%, and 25% of patients still on GCs after respectively 1, 2, and 5 years. • A pooled relapse rate of 43% at 1 year, even remarkable, can only partially explain the long-term GC treatment in PMR. • Several studies have attempted to identify potential predictors of prolonged treatment with GCs and relapse, but with inconsistent results. • Additional research is needed to profile patients with a higher risk of long-term GC treatment and relapse and identify more effective steroid-sparing strategies. |
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Affiliation(s)
- Alberto Floris
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy. .,Dipartimento Di Scienze Mediche E Sanità Pubblica, Università Di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy.
| | - Matteo Piga
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Mattia Congia
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Gian Luca Erre
- Rheumatology Unit, University of Sassari and AOU University Clinic of Sassari, Sassari, Italy
| | - Maria Maddalena Angioni
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Alessandro Mathieu
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Alberto Cauli
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
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The effect of a nurse-led prednisolone tapering regimen in polymyalgia rheumatica: a retrospective cohort study. Rheumatol Int 2020; 41:605-610. [PMID: 32696323 DOI: 10.1007/s00296-020-04654-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/11/2020] [Indexed: 02/01/2023]
Abstract
The objective of this study is to investigate the efficacy of a nurse-led prednisolone tapering regime in patients with polymyalgia rheumatica (PMR) compared to standard care. It is a single-center retrospective cohort study evaluating dose and percentage of patients receiving prednisolone after 1 and 2 years. A nurse-led PMR clinic was introduced June 2015 and patients diagnosed until June 2017 were included. Patients were diagnosed by a rheumatologist, and subsequently managed by nurses according to a specific protocol. Patients diagnosed with PMR between June 2012 and June 2015 served as controls. They received standard care by a rheumatologist. Sixty-eight patients received standard care and 107 nurse-led care. After 1 year, 71% of patients receiving standard care vs. 64% receiving nurse-led care took prednisolone (p = 0.441). Median (interquartile range) prednisolone dose after 1 year was 3.75 mg (0-5) in the standard care group and 1.25 mg (0-3.75) in the nurse-led care group (p = 0.004). After 2 years, 41% of patients receiving standard care vs. 18% receiving nurse-led care took prednisolone (p = 0.003). Prednisolone dose after 2 years was 0 mg (0-2.5) in the standard care group and 0 mg (0-0) in the nurse-led care group (p = 0.004). There was no difference regarding relapse and initiation of methotrexate. The number of patient contacts was 12.5 (5-16.5) in the standard care group vs. 17 (13-23) in the nurse-led care group (p = 0.001). A tight and systematic approach to prednisolone tapering is more effective than standard care, but more frequent patient contacts were necessary to obtain this effect.
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Usefulness of Methotrexate in the Reduction of Relapses and Recurrences in Polymyalgia Rheumatica. ACTA ACUST UNITED AC 2020; 26:S213-S217. [DOI: 10.1097/rhu.0000000000001414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smutny T, Barvik I, Veleta T, Pavek P, Soukup T. Genetic Predispositions of Glucocorticoid Resistance and Therapeutic Outcomes in Polymyalgia Rheumatica and Giant Cell Arteritis. J Clin Med 2019; 8:jcm8050582. [PMID: 31035618 PMCID: PMC6572549 DOI: 10.3390/jcm8050582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/04/2022] Open
Abstract
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related chronic inflammatory diseases. Glucocorticoids (GCs) are first-choice drugs for PMR and GCA, although some patients show poor responsiveness to the initial GC regimen or experience flares after GC tapering. To date, no valid biomarkers have been found to predict which patients are at most risk for developing GC resistance. In this review, we summarize PMR- and GCA-related gene polymorphisms and we associate these gene variants with GC resistance and therapeutic outcomes. A limited number of GC resistance associated-polymorphisms have been published so far, mostly related to HLA-DRB1*04 allele. Other genes such ICAM-1, TLR4 and 9, VEGF, and INFG may play a role, although discrepancies are often found among different populations. We conclude that more studies are required to identify reliable biomarkers of GC resistance. Such biomarkers could help distinguish non-responders from responders to GC treatment, with concomitant consequences for therapeutic strategy.
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Affiliation(s)
- Tomas Smutny
- Department of Pharmacology and Toxicology, Centre for Drug Development, Faculty of Pharmacy in Hradec Kralove, Charles University, 500 05 Hradec Kralove, Czech Republic.
| | - Ivan Barvik
- Institute of Physics, Faculty of Mathematics and Physics, Charles University, 121 16 Prague, Czech Republic.
| | - Tomas Veleta
- Department of Emergency Medicine, University Hospital in Hradec Kralove, 500 05 Hradec Kralove, Czech Republic.
| | - Petr Pavek
- Department of Pharmacology and Toxicology, Centre for Drug Development, Faculty of Pharmacy in Hradec Kralove, Charles University, 500 05 Hradec Kralove, Czech Republic.
| | - Tomas Soukup
- Division of Rheumatology, 2nd Department of Internal Medicine⁻Gastroenterology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital in Hradec Kralove, 500 05 Hradec Kralove, Czech Republic.
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Quartuccio L, Gregoraci G, Isola M, De Vita S. Retrospective analysis of the usefulness of a protocol with high-dose methotrexate in polymyalgia rheumatica: Results of a single-center cohort of 100 patients. Geriatr Gerontol Int 2018; 18:1410-1414. [PMID: 29978586 DOI: 10.1111/ggi.13460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/16/2018] [Accepted: 05/27/2018] [Indexed: 11/27/2022]
Abstract
AIM The aim of the present study was to define subsets of patients suffering from polymyalgia rheumatica, where methotrexate (MTX) up to 20 mg/week might be more effective. METHODS A total of 100 patients with polymyalgia rheumatica treated with MTX were studied. The criteria for MTX introduction were: (i) relapse during the first month of therapy, when tapering glucocorticoids (GC); (ii) requiring long-term GC (i.e. >24 consecutive months); (iii) requiring ≥5 mg/day of prednisone equivalents after 4 months of GC therapy; (iv) GC-related side-effects; and (v) a high risk of GC-related side-effects. All the patients were followed for at least 12 months. A group of patients treated with GC alone in the same center was also compared with the whole MTX group. RESULTS Follow up varied from 12 to 185 months (median 46.5 months). Remission with current prednisone dose ≤2.5 mg/day at month +12 was observed in 59 out of 100 patients; remission with GC suspension at month +12 was observed in 38 out of 100, without significant difference among groups. Approximately half of the patients showed at least one relapse (54/100) during the follow-up period. The cumulative dose of GC was 1.5 g (range 0.1-15.2 g) . New GC-related side-effects were recorded in 16 out of 100 patients at last follow up. Compared with the GC alone group, the MTX group showed younger age, higher prevalence of female sex and higher level of inflammation. CONCLUSIONS MTX up to 20 mg/day was useful in defined subsets of polymyalgia rheumatica, also in the long term. No significant differences were noticed among the five subgroups. Geriatr Gerontol Int 2018; 18: 1410-1414.
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Affiliation(s)
- Luca Quartuccio
- Department of Medical Area, Clinic of Rheumatology, University of Udine, Udine, Italy
| | - Giorgia Gregoraci
- Department of Medical Area, Institute of Statistics, University of Udine, Udine, Italy
| | - Miriam Isola
- Department of Medical Area, Institute of Statistics, University of Udine, Udine, Italy
| | - Salvatore De Vita
- Department of Medical Area, Clinic of Rheumatology, University of Udine, Udine, Italy
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9
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Abstract
Approximately half of PMR patients have a relapse with a necessity to increase GC dosages. The role of external factors in inducing PMR relapse have been poorly investigated. We present a case-series of five PMR patients in remission with low doses of glucocorticosteroids (GC), who presented with relapse immediately after a fall. The assessment of PMR relapse was made using PMR-AS by Leeb and Bird, and a score > 9.35 was consistent with diagnosis of relapse. Gender, age, and cumulative dose of GC at the time of the fall were compared between the group of these five patients and a group of 41 PMR patients who had no PMR relapse after a fall: using the Fischer's exact test a significant difference was pointed out when the p-value was < 0.05. In our five PMR patients, the sharp worsening of clinical manifestations was always accompanied by a significant rise of the inflammatory indices and the increase of GC dosage (almost always 10 mg/day of prednisone) prompted a fast return (seven days as average) to the previous clinical and laboratory features. All other potentially responsible factors were excluded. Several months (6-10 months on average) after the fall, none of these five patients had a new relapse. No significant differences were found when we compared age, sex, and the cumulative dose of GC at the time of the fall between the group of patients with PMR relapse and the group of patients without. The possibility of PMR relapse being realised immediately after a fall should be kept in mind in daily practice, especially when typical manifestations reappear immediately after a fall and other diagnostic hypotheses have been carefully excluded. The lack of important data (genetic factors, hormonal dosages, serum levels of IL-6 and/or serum soluble IL-6 receptor) in our case-series represented important limits for clarifying the nature of our observations and should be included in any subsequent study design on this argument. If our monocentric data are confirmed by multicentric data, the assessment of the risk of falls through specific scales should be an integral part of the visit of all PMR patients.
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Mackie SL, Pease CT, Fukuba E, Harris E, Emery P, Hodgson R, Freeston J, McGonagle D. Whole-body MRI of patients with polymyalgia rheumatica identifies a distinct subset with complete patient-reported response to glucocorticoids. Ann Rheum Dis 2015; 74:2188-92. [PMID: 26376658 PMCID: PMC4680120 DOI: 10.1136/annrheumdis-2015-207395] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/22/2015] [Accepted: 07/14/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine whether whole-body MRI defines clinically relevant subgroups within polymyalgia rheumatica (PMR) including glucocorticoid responsiveness. METHODS 22 patients with PMR and 16 with rheumatoid arthritis (RA), untreated and diagnosed by consultant rheumatologists, underwent whole-body, multiple-joint MRI, scored by two experts. Patients with PMR reported whether they felt 'back to normal' on glucocorticoid therapy and were followed for a median of 2 years. RESULTS All patients with PMR were deemed to respond to glucocorticoids clinically. A characteristic pattern of symmetrical, extracapsular inflammation, adjacent to greater trochanter, acetabulum, ischial tuberosity and/or symphysis pubis, was observed in 14/22 of the PMR cases. In PMR, this pattern was associated with complete glucocorticoid response (p=0.01), higher pretreatment C-reactive protein (CRP) and serum interleukin-6 (IL-6), and better post-treatment fatigue and function. Only 1/14 in the extracapsular group could stop glucocorticoids within 1 year, compared with 4/7 of the others. A score derived from the five sites discriminating best between PMR and RA correlated with IL-6 (p<0.002). IL-6 levels ≥16.8 pg/mL had 86% sensitivity and 86% specificity for the extracapsular MRI pattern. CONCLUSIONS A subset of patients with rheumatologist-diagnosed PMR had a characteristic, extracapsular pattern of MRI inflammation, associated with elevated IL-6/CRP and with complete patient-reported glucocorticoid responsiveness.
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Affiliation(s)
- Sarah Louise Mackie
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | | | - Eiji Fukuba
- Department of Radiology, Shimane University, Izumo, Japan
| | - Emma Harris
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Paul Emery
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Richard Hodgson
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
- University of Manchester Centre for Imaging Sciences, Manchester, UK
| | - Jane Freeston
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Dennis McGonagle
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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Duarte C, Ferreira RJDO, Mackie SL, Kirwan JR, Pereira da Silva JA. Outcome Measures in Polymyalgia Rheumatica. A Systematic Review. J Rheumatol 2015; 42:2503-11. [DOI: 10.3899/jrheum.150515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To identify the instruments used to assess polymyalgia rheumatica (PMR) in published studies.Methods.A systematic literature review of clinical trials and longitudinal observational studies related to PMR, published from 1970 to 2014, was carried out. All outcome and assessment instruments were extracted and categorized according to core areas and domains, as defined by the OMERACT (Outcome Measures in Rheumatology) Filter 2.0.Results.Thirty-five articles (3221 patients) were included: 12 randomized controlled trials (RCT); 3 nonrandomized trials; and 20 observational studies. More than 20 domains were identified, measured by 29 different instruments. The most frequently used measures were pain, morning stiffness, patient global assessment and physician global assessment, erythrocyte sedimentation rate, and C-reactive protein. The definition of outcomes varied considerably between studies.Conclusion.The outcome measures and instruments used in PMR are numerous and diversely defined. The establishment of a core set of validated and standardized outcome measurements is needed.
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Owen CE, Buchanan RRC, Hoi A. Recent advances in polymyalgia rheumatica. Intern Med J 2015; 45:1102-8. [DOI: 10.1111/imj.12823] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 05/25/2015] [Indexed: 12/20/2022]
Affiliation(s)
- C. E. Owen
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
- Department of Medicine; Austin Health; The University of Melbourne; Melbourne Victoria Australia
| | - R. R. C. Buchanan
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
| | - A. Hoi
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
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Schirmer M, Dejaco C, Dasgupta B, Matteson EL. Polymyalgia rheumatica: strategies for efficient practice and quality assurance. Rheumatol Int 2015; 35:1781-9. [PMID: 26032754 DOI: 10.1007/s00296-015-3297-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/21/2015] [Indexed: 11/29/2022]
Abstract
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in persons over the age of 50 years. There are many diseases which mimic PMR, for which reason a careful diagnostic approach is required. While it is thought to be exquisitely responsive to glucocorticosteroid therapy, many patients respond incompletely and/or develop serious side effects over the protracted disease course. Improved methods for classification and disease assessment together with standardized treatment approaches and outcome assessments can serve to improve the care of patients with this disease.
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Affiliation(s)
- Michael Schirmer
- Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria.
| | - Christian Dejaco
- Division of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Westcliff-on-Sea, UK
| | - Eric L Matteson
- Division of Rheumatology, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Twohig H, Mitchell C, Mallen C, Adebajo A, Mathers N. "I suddenly felt I'd aged": a qualitative study of patient experiences of polymyalgia rheumatica (PMR). PATIENT EDUCATION AND COUNSELING 2015; 98:645-650. [PMID: 25638304 DOI: 10.1016/j.pec.2014.12.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/04/2014] [Accepted: 12/31/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To explore patient experiences of living with, and receiving treatment for, PMR. METHODS Semi-structured qualitative interviews, with 22 patients with PMR recruited from general practices in South Yorkshire. Thematic analysis using a constant comparative method, ran concurrently with the interviews and was used to derive a conceptual framework. RESULTS 5 Key themes emerged highlighting the importance of: (1) pain, stiffness and weakness, (2) disability, (3) treatment and disease course, (4) experience of care, (5) psychological impact of PMR. Patients emphasised the profound disability experienced that was often associated with fear and vulnerability, highlighting how this was often not recognised by health care professionals. Patients' experiences also challenge medical convention, particularly around the concept of 'weakness' as a symptom, the use of morning stiffness as a measure of disease activity and the myth of full resolution of symptoms with steroid treatment. Treatment decisions were complex, with patients balancing glucocorticoid side effects against persistent symptoms. CONCLUSIONS Patients often described their experience of PMR in terms of disability rather than focussing on localised symptoms. The associated psychological impact was significant. PRACTICE IMPLICATIONS Recognising this is key to achieving shared understanding, reaching the correct diagnosis promptly, and formulating a patient-centred management plan.
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Affiliation(s)
- Helen Twohig
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK.
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK.
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Adewale Adebajo
- Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK.
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK.
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Liozon E, Wig R, Vogt N, Michel JP, Gold G. POLYMYALGIA RHEUMATICA FOLLOWING INFLUENZA VACCINATION. J Am Geriatr Soc 2015. [DOI: 10.1111/jgs.2000.48.11.1533a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVES On the 125th anniversary of the first recognised publication on polymyalgia rheumatica, a review of the literature was undertaken to assess what progress has been made from the point of view of the clinical care of affected patients. METHODS The authors searched Medline and PubMed using the search terms 'polymyalgia rheumatica', 'giant cell arteritis' and 'temporal arteritis'. As much as possible, efforts were made to focus on studies where polymyalgia rheumatica and giant cell arteritis were treated as separate entities. The selection of articles was influenced by the authors' bias that polymyalgia rheumatica is a separate clinical condition from giant cell arteritis and that, as yet, the diagnosis is a clinical one. Apart from the elevation of circulating acute phase proteins, which has been recognised as a feature of polymyalgia rheumatica for over 60 years, the diagnosis receives no significant help from the laboratory or from diagnostic imaging. RESULTS This review has shown that, following the recognition of polymyalgia as a distinct clinical problem of the elderly, the results of a considerable amount of research efforts including those using the advances in clinical imaging technology over the past 60 years, have done little to change the ability of clinicians to define the disease more accurately. Since the introduction of corticosteroids in the 1950s, there has been also very little change in the clinical management of the condition. CONCLUSIONS Polymyalgia rheumatica remains a clinical enigma, and its relationship to giant cell arteritis is no clearer now than it has been for the past 125 years. Diagnosing this disease is still almost exclusively dependent on the clinical acumen of a patient's medical attendant. Until an objective method of identifying it clearly in the clinical setting is available, uncovering the aetiology is still unlikely, and until then, preventing the pain and stiffness of the disease while avoiding the problems of prolonged exoposure to corticosteroids is likely to remain elusive or serendipitous.
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Affiliation(s)
- Patrick J Rooney
- Professor of Medicine, Department of Clinical Skills, St George's University, Grenada
| | - Jennifer Rooney
- Associate Professor of Medicine, Department of Clinical Skills, St George's University, Grenada
| | - Geza Balint
- Consultant Rheumatologist, National Institute of Rheumatology and Physiotherapy, Hungary
| | - Peter Balint
- Head of Department and Consultant Rheumatologist, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Hungary
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Hayward RA, Rathod T, Muller S, Hider SL, Roddy E, Mallen CD. Association of polymyalgia rheumatica with socioeconomic status in primary care: a cross-sectional observational study. Arthritis Care Res (Hoboken) 2014; 66:956-60. [PMID: 24403212 PMCID: PMC4171747 DOI: 10.1002/acr.22276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/27/2013] [Accepted: 12/27/2013] [Indexed: 11/17/2022]
Abstract
Objective Polymyalgia rheumatica (PMR) is an inflammatory musculoskeletal condition predominantly diagnosed and managed in the community. Socioeconomic status (SES) is known to be associated with many inflammatory rheumatologic conditions, but has not been investigated in relation to PMR. This study aimed to investigate the association between PMR and SES at both the area and individual levels. Methods Patients ages >50 years registered with 8 general practices in North Staffordshire were sent a questionnaire requesting details of their general health, SES, and lifestyle. Individual SES was measured using occupation, educational level, and perceived adequacy of income. Area-level SES was measured using the Index of Multiple Deprivation, derived from respondents' postcodes. Electronic primary care medical records were searched for Read code diagnoses of PMR 2 years before and after the survey. Results Of the 13,831 respondents, 141 had a recorded PMR diagnosis in their electronic medical records, a prevalence of 10 per 1,000 patients. No association between PMR and SES was seen at either the individual or area level. Conclusion No association was found between PMR and SES at either the area or individual level. Unlike several of the inflammatory arthritides that are more common in the more deprived areas, PMR shows no such association. In part this may be due to PMR affecting an older population. Although socioeconomic factors are important for clinicians and researchers to consider, in patients with PMR, further epidemiologic work is needed to fully characterize this disabling disorder.
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Mori S, Koga Y. Glucocorticoid-resistant polymyalgia rheumatica: pretreatment characteristics and tocilizumab therapy. Clin Rheumatol 2014; 35:1367-75. [PMID: 24803231 PMCID: PMC4844628 DOI: 10.1007/s10067-014-2650-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/24/2014] [Accepted: 04/25/2014] [Indexed: 11/29/2022]
Abstract
Treatment with glucocorticoid (GC) is the preferred therapy for polymyalgia rheumatica (PMR), but some patients show poor responses to the initial GC regimen or experience flares on GC tapering. Alternative therapies for patients with GC resistance have not yet been established. To evaluate pretreatment characteristics and therapeutic outcomes of GC-resistant PMR, we followed all patients who had been diagnosed with PMR between October 2007 and February 2013, according to our standardized protocol. GC-resistant patients were defined as those who had responded poorly to the initial GC regimen (15 mg/day of prednisolone) or those who had responded to the initial regimen but had experienced a flare upon GC tapering to 5 mg/day of the maintenance dose or within the first 6 months of maintenance therapy. Out of 23 patients, nine were found to be GC-resistant cases and the others were GC responders. Baseline values of PMR activity score and its components, especially the ability to elevate the upper limbs (EUL), were significantly higher in GC-resistant patients compared with GC responders. The additional use of methotrexate (MTX, five cases), salazosulfapyridine (one case), and tocilizumab (TCZ, three cases) was effective for GC-resistant patients, although 13 to 39 weeks were required for the achievement of remission. We report the three GC-resistant cases in which TCZ was added to GC therapy with or without MTX. We also review the medical literature on the use of TCZ as of January 31, 2014 and discuss the utility of TCZ in the treatment of GC-resistant PMR.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto, 861-1196, Japan.
| | - Yukinori Koga
- Department of Radiology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
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Faez S, Lobo AM, Unizony SH, Stone JH, Papaliodis GN, Sobrin L. Ocular inflammatory disease in patients with polymyalgia rheumatica: A case series and review of the literature. Clin Rheumatol 2014; 35:251-8. [PMID: 24696366 DOI: 10.1007/s10067-014-2558-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 02/23/2014] [Indexed: 12/14/2022]
Abstract
Scleritis and uveitis are potentially blinding conditions that can be associated with systemic inflammatory diseases. Polymyalgia rheumatica (PMR) is a common rheumatic disorder of the elderly of uncertain etiology. Although there are a few published reports of scleritis and uveitis in PMR patients, the association of PMR to ocular inflammation has not been well established. The aim of this study is to report a series of PMR patients with scleritis and/or uveitis and review the prior published reports of this potential association. We retrospectively reviewed the medical charts of patients with PMR and scleritis or uveitis who were examined in the Ocular Immunology Service of Massachusetts Eye and Ear Infirmary. We also performed a systematic literature search (PubMed; January 1990 until January 2014) to identify earlier published reports. Seven PMR patients with ocular inflammatory disease (OID) were included in our study: two with scleritis, three with anterior uveitis, and two with panuveitis. The onset of PMR preceded the occurrence of OID in six patients, and in one patient uveitis developed 2 months prior to PMR. Five patients demonstrated a temporal association between flares of PMR and OID. In four patients, OID flares developed during tapering of systemic prednisone prescribed for PMR. Four of the five patients who had relapsing PMR had recurrent or persistent uveitis over the course of follow-up. PMR may be associated with both scleritis and uveitis and should be considered as a possible underlying cause of OID.
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Affiliation(s)
- Sepideh Faez
- Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA
| | - Ann-Marie Lobo
- Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA
| | - Sebastian H Unizony
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - George N Papaliodis
- Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA
| | - Lucia Sobrin
- Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA. .,Retina Division, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA.
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Mano Y, Yoshizawa A, Itabashi Y, Ohki T, Takahashi T, Mori M, Shin H, Tanaka Y. Left atrial myxoma detected after an initial diagnosis of polymyalgia rheumatica. Intern Med 2014; 53:441-4. [PMID: 24583432 DOI: 10.2169/internalmedicine.53.1300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the case of a 69-year-old woman with left atrial myxoma detected following treatment with glucocorticoids for an initial diagnosis of polymyalgia rheumatica (PMR). The glucocorticoids markedly improved the patient's symptoms, and the tumor was excised after rapidly tapering the glucocorticoid dose. The PMR-like symptoms did not recur and the inflammatory marker levels returned to normal after surgery. The patient's clinical course indicated that the initial PMR-like symptoms were entirely caused by the left atrial myxoma. This case demonstrates that glucocorticoid treatment for suspected PMR can mask the symptoms of myxoma, leading to a delay in diagnosis.
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Affiliation(s)
- Yoshinori Mano
- Department of Cardiology, Tokyo Dental College, Ichikawa General Hospital, Japan
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Marie I. Maladie de Horton et pseudopolyarthrite rhizomélique : critères diagnostiques. Rev Med Interne 2013; 34:403-11. [DOI: 10.1016/j.revmed.2013.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
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Macchioni P, Boiardi L, Catanoso M, Pulsatelli L, Pipitone N, Meliconi R, Salvarani C. Tocilizumab for polymyalgia rheumatica: report of two cases and review of the literature. Semin Arthritis Rheum 2013; 43:113-8. [PMID: 23433960 DOI: 10.1016/j.semarthrit.2013.01.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/07/2013] [Accepted: 01/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Glucocorticoids (GC) are the mainstay of treatment of polymyalgia rheumatica (PMR). However GC-related adverse events occur frequently, particularly in patients with relapsing disease. Several studies have demonstrated that IL-6 is a key player in the pathogenesis of PMR. OBJECTIVES To report 2 patients with PMR treated with the anti-IL-6 receptor monoclonal antibody tocilizumab (TCZ) and to review the published evidence on the efficacy and safety of TCZ in patients with PMR. METHODS We treated 2 GC-naive patients with newly diagnosed pure PMR with monthly TCZ infusions (8mg/kg body weight) for 6 months. Disease activity and drug tolerability were assessed clinically, by laboratory tests, and bilateral shoulder ultrasonography before starting the treatment and subsequently every month during TCZ therapy. We performed a systematic literature search (PubMed until July 2012) using the terms "tocilizumab," "anti-IL-6-receptor," "polymyalgia rheumatica," "giant cell arteritis", and "large-vessel vasculitis" to identify published reports of patients with PMR treated with TCZ. RESULTS One of our patients responded well to TCZ, while the other patient required GC therapy after the 2nd TCZ infusion because of lack of appreciable clinical response. Both patients tolerated TCZ well. The review of the literature revealed 4 reports with a total of 9 patients who received TCZ for PMR. In 7 of these 9 patients, PMR was associated with giant cell arteritis. Including our patients, 5 patients received TCZ alone and 6 TCZ plus GC. A good response to TCZ treatment was observed in all patients reported in the literature without any major adverse events. CONCLUSIONS TCZ both as monotherapy and in association with GC appears to be mostly effective and safe to treat patients with PMR. However, larger controlled studies are required to confirm these favorable data.
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Affiliation(s)
- Pierluigi Macchioni
- Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
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Dasgupta B, Cimmino MA, Kremers HM, Schmidt WA, Schirmer M, Salvarani C, Bachta A, Dejaco C, Duftner C, Jensen HS, Duhaut P, Poór G, Kaposi NP, Mandl P, Balint PV, Schmidt Z, Iagnocco A, Nannini C, Cantini F, Macchioni P, Pipitone N, Del Amo M, Espígol-Frigolé G, Cid MC, Martínez-Taboada VM, Nordborg E, Direskeneli H, Aydin SZ, Ahmed K, Hazleman B, Silverman B, Pease C, Wakefield RJ, Luqmani R, Abril A, Michet CJ, Marcus R, Gonter NJ, Maz M, Carter RE, Crowson CS, Matteson EL. 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. ACTA ACUST UNITED AC 2012; 64:943-54. [PMID: 22389040 DOI: 10.1002/art.34356] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The objective of this study was to develop European League Against Rheumatism/American College of Rheumatology classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new-onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of rheumatoid factor and/or anti-citrullinated protein antibody (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness >45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain. These criteria are not meant for diagnostic purposes.
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Dasgupta B, Cimmino MA, Maradit-Kremers H, Schmidt WA, Schirmer M, Salvarani C, Bachta A, Dejaco C, Duftner C, Jensen HS, Duhaut P, Poór G, Kaposi NP, Mandl P, Balint PV, Schmidt Z, Iagnocco A, Nannini C, Cantini F, Macchioni P, Pipitone N, Amo MD, Espígol-Frigolé G, Cid MC, Martínez-Taboada VM, Nordborg E, Direskeneli H, Aydin SZ, Ahmed K, Hazleman B, Silverman B, Pease C, Wakefield RJ, Luqmani R, Abril A, Michet CJ, Marcus R, Gonter NJ, Maz M, Carter RE, Crowson CS, Matteson EL. 2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2012; 71:484-92. [PMID: 22388996 PMCID: PMC3298664 DOI: 10.1136/annrheumdis-2011-200329] [Citation(s) in RCA: 312] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.
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Affiliation(s)
- Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Westcliff-on-Sea, Essex, UK
| | - Marco A Cimmino
- Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Wolfgang A Schmidt
- Department of Rheumatology, Immanuel Krankenhaus Berlin: Medical Center for Rheumatology Berlin–Buch Berlin, Berlin, Germany
| | - Michael Schirmer
- Department of Internal Medicine I, Innsbruck Medical University, Innsbruck, Austria
| | - Carlo Salvarani
- Department of Rheumatology, Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Artur Bachta
- Department of Internal Medicine and Rheumatology, Military Institute of Medicine, Warsaw, Poland
| | - Christian Dejaco
- Department of Rheumatology, Medical University Graz, Graz, Austria
| | - Christina Duftner
- Department of Internal Medicine I, Innsbruck Medical University, Innsbruck, Austria
- Department of Internal Medicine, General Hospital of Kufstein, Kufstein, Austria
| | | | | | - Gyula Poór
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Novák Pál Kaposi
- Radiology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Peter Mandl
- General and Pediatric Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Peter V Balint
- General and Pediatric Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Zsuzsa Schmidt
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Annamaria Iagnocco
- Rheumatology Unit, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | | | | | | | - Nicolò Pipitone
- Department of Rheumatology, Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | | | - Georgina Espígol-Frigolé
- Department of Systemic Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Maria C Cid
- Department of Systemic Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Víctor M Martínez-Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Elisabeth Nordborg
- Sahlgren University Hospital, Department of Rheumatology, Göteborg, Sweden
| | - Haner Direskeneli
- Department of Rheumatology, Marmara University Medical School, Istanbul, Turkey
| | - Sibel Zehra Aydin
- Department of Rheumatology, Marmara University Medical School, Istanbul, Turkey
| | - Khalid Ahmed
- Department of Rheumatology, Princess Alexandra Hospital, Harlow, UK
| | - Brian Hazleman
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | | | - Colin Pease
- Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, UK
| | - Richard J Wakefield
- Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, UK
| | - Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Andy Abril
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Clement J Michet
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ralph Marcus
- Rheumatology Associates of North Jersey, Teaneck, New Jersey, USA
| | - Neil J Gonter
- Rheumatology Associates of North Jersey, Teaneck, New Jersey, USA
| | - Mehrdad Maz
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia S Crowson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric L Matteson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Villa I, Agudo Bilbao M, Martínez-Taboada VM. Avances en el diagnóstico de las vasculitis de vasos de gran calibre: identificación de biomarcadores y estudios de imagen. ACTA ACUST UNITED AC 2011; 7 Suppl 3:S22-7. [DOI: 10.1016/j.reuma.2011.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 09/28/2011] [Indexed: 11/26/2022]
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Dejaco C, Duftner C, Dasgupta B, Matteson EL, Schirmer M. Polymyalgia rheumatica and giant cell arteritis: management of two diseases of the elderly. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.50] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) present with a broad spectrum of clinical manifestations and almost exclusively occur in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries and/or aorta are more often involved in GCA than previously estimated. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or 18F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in these diseases. This article highlights upcoming new classification criteria for PMR, recent advances of diagnostic and therapeutic procedures as well as ongoing research on biomarkers and corticosteroid-sparing medications, which should improve management of PMR and GCA.
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Affiliation(s)
- Christian Dejaco
- Department of Rheumatology & Immunology, Medical University of Graz, Auenbruggerplatz 2/4, A-8036 Graz, Austria
| | - Christina Duftner
- Department of Internal Medicine, Bezirkskrankenhaus Kufstein, Endach 27, A-6330 Kufstein, Austria
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Essex, UK
| | - Eric L Matteson
- Division of Rheumatology & Division of Epidemiology, Departments of Internal Medicine & Health Sciences Research Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael Schirmer
- Department of Internal Medicine I, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Cimmino MA, Parodi M, Montecucco C, Caporali R. The correct prednisone starting dose in polymyalgia rheumatica is related to body weight but not to disease severity. BMC Musculoskelet Disord 2011; 12:94. [PMID: 21569559 PMCID: PMC3114801 DOI: 10.1186/1471-2474-12-94] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 05/14/2011] [Indexed: 11/10/2022] Open
Abstract
Background the mainstay of treatment of polymyalgia rheumatica (PMR) is oral glucocorticoids, but randomized controlled trials of treatment are lacking. As a result, there is no evidence from controlled studies on the efficacy of different initial doses or glucocorticoid tapering. The aim of this study is to test if 12.5 mg prednisone/day is an adequate starting dose in PMR and to evaluate clinical predictors of drug response. Methods 60 consecutive PMR patients were treated with a starting dose of 12,5 mg/day prednisone. Clinical, laboratory, and, in a subset of 25 patients, ultrasonographic features were recorded as possible predictors of response to prednisone. Remission was defined as disappearance of at least 75% of the signs and symptoms of PMR and normalization of ESR and CRP within the first month, a scenario allowing steroid tapering. Results 47/60 (78.3%) patients responded to 12.5 mg of prednisone after a mean interval of 6.6 ± 5.2 days. In univariate analysis, body weight and gender discriminated the two groups. In multivariate analysis, the only factor predicting a good response was low weight (p = 0.004); the higher response rate observed in women was explained by their lower weight. The mean prednisone dose per kg in the responders was 0.19 ± 0.03 mg in comparison with 0.16 ± 0.03 mg for non responders (p = 0.007). Conclusions 12.5 mg prednisone is a sufficient starting dose in ¾ of PMR patients. The main factor driving response to prednisone in PMR was weight, a finding that could help in the clinical care of PMR patients and in designing prospective studies of treatment. Trial Registration ClinicalTrials.gov: NCT01169597
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Affiliation(s)
- Marco A Cimmino
- Clinica Reumatologica, Dipartimento di Medicina Interna, Università di Genova, Viale Benedetto XV, 6, 16132 Genova, Italy.
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Weyand CM, Goronzy JJ. Polymyalgia rheumatica and giant cell arteritis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Dejaco C, Duftner C, Cimmino MA, Dasgupta B, Salvarani C, Crowson CS, Maradit-Kremers H, Hutchings A, Matteson EL, Schirmer M. Definition of remission and relapse in polymyalgia rheumatica: data from a literature search compared with a Delphi-based expert consensus. Ann Rheum Dis 2010; 70:447-53. [PMID: 21097803 PMCID: PMC3033531 DOI: 10.1136/ard.2010.133850] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To compare current definitions of remission and relapse in polymyalgia rheumatica (PMR) with items resulting from a Delphi-based expert consensus. Methods Relevant studies including definitions of PMR remission and relapse were identified by literature search in PubMed. The questionnaire used for the Delphi survey included clinical (n=33), laboratory (n=54) and imaging (n=7) parameters retrieved from a literature search. Each item was assessed for importance and availability/practicability, and limits were considered for metric parameters. Consensus was defined by an agreement rate of ≥80%. Results Out of 6031 articles screened, definitions of PMR remission and relapse were available in 18 and 34 studies, respectively. Parameters used to define remission and/or relapse included history and clinical assessment of pain and synovitis, constitutional symptoms, morning stiffness (MS), physician's global assessment, headache, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood count, fibrinogen and/or corticosteroid therapy. In the Delphi exercise a consensus was obtained on the following parameters deemed essential for definitions of remission and relapse: patient's pain assessment, MS, ESR, CRP, shoulder and hip pain on clinical examination, limitation of upper limb elevation, and assessment of corticosteroid dose required to control symptoms. Conclusions Assessment of patient's pain, MS, ESR, CRP, shoulder pain/limitation on clinical examination and corticosteroid dose are considered to be important in current available definitions of PMR remission and relapse and the present expert consensus. The high relevance of clinical assessment of hips was unique to this study and may improve specificity and sensitivity of definitions for remission and relapse in PMR.
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Affiliation(s)
- Christian Dejaco
- Correspondence to Professor Michael Schirmer, Department of Internal Medicine I, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Study of professional practices among rheumatologists in Burgundy: initial corticotherapy in polymyalgia rheumatica. Clin Rheumatol 2010; 30:51-6. [DOI: 10.1007/s10067-010-1619-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 10/13/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
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SPIES CORNELIAM, CUTOLO MAURIZIO, STRAUB RAINERH, BURMESTER GERDRÜDIGER, BUTTGEREIT FRANK. More Night Than Day — Circadian Rhythms in Polymyalgia Rheumatica and Ankylosing Spondylitis. J Rheumatol 2010; 37:894-9. [DOI: 10.3899/jrheum.091283] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The circadian rhythm of symptoms in patients with chronic inflammatory diseases is well known. Circadian rhythms could be used to identify targets for time-adapted antiinflammatory therapies, which are administered prior to the flare of cytokine synthesis and inflammatory activity. In recent years, the diurnal variations in rheumatoid arthritis have been described precisely for pain, stiffness, and functional disability, as well as the underlying cyclic variations in hormone levels and cytokine concentrations. This review summarizes the current knowledge on circadian rhythms in other rheumatic diseases, focusing on polymyalgia rheumatica and ankylosing spondylitis.
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Mackie SL, Hensor EMA, Haugeberg G, Bhakta B, Pease CT. Can the prognosis of polymyalgia rheumatica be predicted at disease onset? Results from a 5-year prospective study. Rheumatology (Oxford) 2010; 49:716-22. [DOI: 10.1093/rheumatology/kep395] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ciccarelli M, Jeanmonod D, Jeanmonod R. Giant cell temporal arteritis with a normal erythrocyte sedimentation rate: report of a case. Am J Emerg Med 2009; 27:255.e1-3. [DOI: 10.1016/j.ajem.2008.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Accepted: 06/26/2008] [Indexed: 11/25/2022] Open
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Martinez-Taboada VM, Alvarez L, RuizSoto M, Marin-Vidalled MJ, Lopez-Hoyos M. Giant cell arteritis and polymyalgia rheumatica: Role of cytokines in the pathogenesis and implications for treatment. Cytokine 2008; 44:207-20. [DOI: 10.1016/j.cyto.2008.09.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 09/22/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
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Pulsatelli L, Boiardi L, Pignotti E, Dolzani P, Silvestri T, Macchioni P, Cantini F, Salvarani C, Facchini A, Meliconi R. Serum interleukin-6 receptor in polymyalgia rheumatica: A potential marker of relapse/recurrence risk. ACTA ACUST UNITED AC 2008; 59:1147-54. [DOI: 10.1002/art.23924] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Polymyalgia rheumatica and giant-cell arteritis are closely related disorders that affect people of middle age and older. They frequently occur together. Both are syndromes of unknown cause, but genetic and environmental factors might have a role in their pathogenesis. The symptoms of polymyalgia rheumatica seem to be related to synovitis of proximal joints and extra-articular synovial structures. Giant-cell arteritis primarily affects the aorta and its extracranial branches. The clinical findings in giant-cell arteritis are broad, but commonly include visual loss, headache, scalp tenderness, jaw claudication, cerebrovascular accidents, aortic arch syndrome, thoracic aorta aneurysm, and dissection. Glucocorticosteroids are the cornerstone of treatment of both polymyalgia rheumatica and giant-cell arteritis. Some patients have a chronic course and might need glucocorticosteroids for several years. Adverse events of glucocorticosteroids affect more than 50% of patients. Trials of steroid-sparing drugs have yielded conflicting results. A greater understanding of the molecular mechanisms involved in the pathogenesis should provide new targets for therapy.
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Affiliation(s)
- Carlo Salvarani
- Unit of Rheumatology, Arcispedale S Maria Nuova, Reggio Emilia, Italy.
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Vasculitides. PRIMER ON THE RHEUMATIC DISEASES 2008. [PMCID: PMC7193731 DOI: 10.1007/978-0-387-68566-3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Despite the spatial closeness of blood vessels and inflammatory cells, blood vessel walls are infrequently targeted by inflammation. Giant cell arteritis (GCA) and Takayasu’s arteritis (TA) are characterized by inflammation directed against the vessel wall. GCA and TA display stringent tissue tropism and affect defined vascular territories in a preferential manner. GCA predominantly affects the second- to fifth-order aortic branches, often in the extracranial arteries of the head. The aorta itself may also be affected in GCA, albeit less often than other regions. In contrast, in TA, the aorta and its major branches are the prime disease targets.
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Dayer E, Dayer JM, Roux-Lombard P. Primer: the practical use of biological markers of rheumatic and systemic inflammatory diseases. ACTA ACUST UNITED AC 2007; 3:512-20. [PMID: 17762850 DOI: 10.1038/ncprheum0572] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Accepted: 05/29/2007] [Indexed: 01/16/2023]
Abstract
The assessment of systemic inflammation by means of laboratory tests often complements the results of medical examination. Traditionally, the erythrocyte sedimentation rate and leukocytosis with left shift are diagnostic markers for inflammatory and infectious diseases. The levels of acute-phase proteins--especially C-reactive protein--are used to assess both the presence of inflammation and any response to treatment. The determination of C-reactive protein levels may be advised in three types of pathological situation: infection, acute or chronic inflammation, and evaluation of metabolic risk. Procalcitonin is useful as a marker of sepsis and severe infection. The concentration of serum amyloid A predicts the chances of survival of patients with secondary (AA) amyloidosis. Ferritin and its glycosylated form are of interest in the study of specific diseases such as adult-onset Still's disease. Markers of cartilage and bone turnover are complementary to these markers of inflammation. Although cytokine serum levels are transiently crucial to the generation of inflammation, their usefulness in the clinic is still under investigation. Serum concentrations of cytokine inhibitors or soluble cytokine receptors, as well as the clinical response of patients to treatment with cytokine antagonists, might generate important information for monitoring autoinflammatory diseases.
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Affiliation(s)
- Eric Dayer
- Centre Hospitalier du Centre du Valais, Sion, Switzerland.
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Hernández-Rodríguez J, Font C, García-Martínez A, Espígol-Frigolé G, Sanmartí R, Cañete JD, Grau JM, Cid MC. Development of ischemic complications in patients with giant cell arteritis presenting with apparently isolated polymyalgia rheumatica: study of a series of 100 patients. Medicine (Baltimore) 2007; 86:233-241. [PMID: 17632265 DOI: 10.1097/md.0b013e318145275c] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Several studies suggest that patients with giant cell arteritis (GCA) presenting with isolated polymyalgia rheumatica (PMR) with no cranial symptoms are at low risk of suffering GCA-related ischemic events. However, the issue remains controversial. In the current study we assessed the development of ischemic events in a large series of GCA patients who suffered from apparently isolated PMR during the main course of their disease. One hundred GCA patients presenting with PMR only for at least 2 months were selected from among 347 individuals with biopsy-proven GCA. Clinical manifestations and their chronologic appearance before diagnosis were recorded. Seventy-three patients presented with isolated PMR for a median of 8 months (range, 2 mo-5 yr) and later developed cranial symptoms for a median of 3 weeks (range, 0 wk-1 yr), which eventually led to GCA diagnosis (Group 1). The remaining 27 patients, after presenting a self-limiting course of dismissed mild cranial symptoms lasting for a median of 2 weeks (range, 1 wk-4 mo), developed PMR, which was their chief complaint for a median of 3 months (range, 2 mo-1.5 yr) and the reason for medical evaluation (Group 2). Twenty (27.4%) patients in Group 1 suffered disease-related ischemic complications at the time of diagnosis. No patient in Group 2 developed ischemic events. Patients with GCA presenting with apparently isolated PMR are not a benign subset and have a significant risk of developing ischemic complications. Among them, the only patients who appear to be at low risk of developing ischemic events are those in whom a self-limiting episode of cranial symptoms can be recorded.
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Affiliation(s)
- José Hernández-Rodríguez
- From Vasculitis Research Unit, Department of Internal Medicine (JH-R, CF, AGM, GE-F, JMG, MCC) and Department of Rheumatology (RS, JDC), Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Abstract
Vasculitis represents an uncommon but important group of disease entities that may affect older patients. The most common vasculitic disease in humans in giant cell arteritis, a disease process seen almost exclusively in patients older than 50 years in age. Vasculitic disease in geriatric patients presents unique challenges with regard to diagnosis and treatment. A thorough understanding of the vasculitic disease entities that may affect older patients as well as their diagnosis and management is essential in minimizing disease and treatment-related morbidity and mortality.
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Affiliation(s)
- Carol A Langford
- Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue, A50, Cleveland, OH 44195, USA.
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Hutchings A, Hollywood J, Lamping DL, Pease CT, Chakravarty K, Silverman B, Choy EHS, Scott DGI, Hazleman BL, Bourke B, Gendi N, Dasgupta B. Clinical outcomes, quality of life, and diagnostic uncertainty in the first year of polymyalgia rheumatica. ACTA ACUST UNITED AC 2007; 57:803-9. [PMID: 17530680 DOI: 10.1002/art.22777] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the impact of polymyalgia rheumatica (PMR) on clinical outcomes and quality of life (QOL); the relationship between laboratory measures and clinical outcomes, and changes in QOL; and agreement between rheumatologists in confirming the initial diagnosis. METHODS We conducted a prospective study of 129 participants in 8 hospitals in England who met a modified version of the Jones and Hazleman criteria and had not started steroid therapy. The main outcome measures were response to steroids after 3 weeks (minimum 50% improvement in proximal pain, morning stiffness <30 minutes, acute-phase response not elevated), relapses, QOL as measured by the Short Form 36 and Health Assessment Questionnaire, and diagnosis reassessment at 1 year. RESULTS At 3 weeks, 55% of participants failed to meet our definition of a complete response to steroid therapy. Both physical and mental QOL at presentation were substantially lower than general population norms and improved by 12.6 (95% confidence interval [95% CI] 10.8, 14.4) and 11.2 (95% CI 8.5, 13.8) points, respectively, at 1 year. Proximal pain and longer morning stiffness were significantly associated with lower physical QOL during followup, whereas erythrocyte sedimentation rate was most strongly associated with lower mental QOL during followup. There was moderate agreement between clinicians in confirming the PMR diagnosis (kappa coefficients 0.49-0.65). CONCLUSION PMR is a heterogeneous disease with a major impact on QOL. Ongoing monitoring should include disease activity based on symptoms, emergence of alternative diagnoses, and early referral of atypical and severe cases.
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Leeb BF, Rintelen B, Sautner J, Fassl C, Bird HA. The polymyalgia rheumatica activity score in daily use: Proposal for a definition of remission. ACTA ACUST UNITED AC 2007; 57:810-5. [PMID: 17530664 DOI: 10.1002/art.22771] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To confirm the reliability and applicability of the Polymyalgia Rheumatica Disease Activity Score (PMR-AS), and to establish a threshold for remission. METHODS First, 78 patients with PMR (50 women/28 men, mean age 65.97 years) were enrolled in a cross-sectional evaluation. The PMR-AS, patient's satisfaction with disease status (PATSAT; range 1-5), erythrocyte sedimentation rate (ESR; first hour), and a visual analog scale of patients' general health assessment (VAS patient global; range 0-100) were recorded. Subsequently, another 39 PMR patients (24 women/15 men, mean age 68.12 years) were followed longitudinally. Relationships between the PMR-AS, PATSAT, ESR, and VAS patient global were analyzed by the Kruskal-Wallis test, Spearman's rank correlation, and kappa statistics. PMR-AS values in patients with a PATSAT score of 1 and a VAS patient global <10 formed the basis to establish a remission threshold. RESULTS PMR-AS values were significantly related to PATSAT (P < 0.001), VAS patient global (P < 0.001), and ESR (P < 0.01). PATSAT and VAS patient global were reasonably different (kappa = 0.226). The median PMR-AS score in patients with PATSAT score 1 and VAS patient global <10 was 0.7 (range 0-3.3), and the respective 75th percentile was 1.3. To enhance applicability, a range from 0 to 1.5 was proposed to define remission in PMR. The median ESR in these patients was 10 mm/hour (range 3-28), indicating external validity. CONCLUSION We demonstrated the reliability, validity, and applicability of the PMR-AS in daily routine. Moreover, we proposed a remission threshold (0-1.5) founded on patient-dependent parameters.
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Affiliation(s)
- Burkhard F Leeb
- Lower Austrian Center for Rheumatology, State Hospital Stockerau, Stockerau, Austria.
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46
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Abstract
Polymyalgia rheumatica (PMR) is a common disorder in the elderly population. The diagnosis is based upon recognition of a clinical syndrome, consisting of pain and stiffness in the shoulder and pelvic girdle, muscle tenderness of the upper and lower limbs and nonspecific somatic complaints. In addition, in most cases the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration are highly elevated. Although PMR and giant cell arteritis (GCA) are commonly regarded as two clinical variations of the same disease, their clinical picture is quite different. Whilst in PMR the musculoskeletal symptoms predominate, the major features of GCA are arterial inflammation and its consequences, which suggests clinical and pathological discrepancies between the two syndromes and important differences with respect to morbidity and mortality. The prognosis of correctly diagnosed PMR is excellent. It is well known that corticosteroid therapy in PMR usually leads to rapid and dramatic improvement of patients' complaints and returns them to previous functional status. However, prolonged corticosteroid treatment, sometimes for several years, may be necessary to maintain clinical improvement. Despite all the knowledge about the beneficial effects of corticosteroid treatment, data concerning the optimal dosage regimen are lacking. Long-term corticosteroid use can be associated with various adverse events, of which induction of osteoporosis, diabetes mellitus and infection among the worst. A Corticosteroid Side Effect Questionnaire has been shown to dose-dependently detect adverse effects perceived by patients. The European League Against Rheumatism (EULAR) response criteria for PMR comprise a core set of markers for monitoring therapeutic responses in PMR, namely ESR or CRP, the visual analogue scale of patient's pain and physician's global assessment, as well as morning stiffness and the ability to elevate the upper limbs. The PMR-disease activity score has been developed on the basis of EULAR response criteria as a means of expressing disease activity as an absolute number. A score <7 indicates low disease activity, scores 7-17 suggest medium activity, and a score >17 is indicative of high disease activity. The PMR-disease activity score has been proven to be highly correlated with patient's global assessment, patient satisfaction and ESR. It provides an easily applicable and valid tool for disease activity monitoring in patients with PMR. Improved knowledge of disease activity processes, exact monitoring of disease activity and treatment responses, and increased risk-estimation of treatment schedules should ultimately improve the care of patients with PMR.
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Affiliation(s)
- Thomas Nothnagl
- 1st and 2nd Department of Medicine, Centre for Rheumatology, Humanisklinikum Lower Austria, Stockerau, Landstrasse, Austria
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Soubrier M, Dubost JJ, Ristori JM. Polymyalgia rheumatica: diagnosis and treatment. Joint Bone Spine 2006; 73:599-605. [PMID: 17113808 DOI: 10.1016/j.jbspin.2006.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 09/06/2006] [Indexed: 11/29/2022]
Abstract
Polymyalgia rheumatica (PMR) typically manifests as inflammatory pain in the shoulder and/or pelvic girdles in a patient over 50 years of age. This condition was long underrecognized and therefore underdiagnosed. Today, however, overdiagnosis may occur. Physicians must be aware that many conditions may simulate PMR, including diseases that carry a grim prognosis or require urgent treatment. PMR may be the first manifestation of giant cell arteritis, and a painstaking search for other signs is mandatory. PMR may inaugurate other rheumatologic diseases such as rheumatoid arthritis, RS3PE syndrome, spondyloarthropathy, systemic lupus erythematosus (SLE), myopathy, vasculitis, and chondrocalcinosis. Finally, PMR may be the first manifestation of an endocrine disorder, a malignancy, or an infection. Failure to respond to glucocorticoid therapy should suggest giant cell arteritis, malignant disease, or infection. Ultrasonography may assist in the diagnosis by showing bilateral subdeltoid bursitis. Glucocorticoids are the mainstay of the treatment of PMR. Although the optimal starting dosage and tapering schedule are not agreed on, a low starting dosage and slow tapering may decrease the relapse rate. Methotrexate is probably useful when glucocorticoid dependency develops. In contrast, TNF-alpha antagonists are probably ineffective.
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Affiliation(s)
- Martin Soubrier
- Service de Rhumatologie, CHU de Clermont-Ferrand, place Henri-Dunant, BP 69, 63003 Clermont-Ferrand cedex 1, France.
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Bablekos GD, Michaelides SA, Karachalios GN, Nicolaou IN, Batistatou AK, Charalabopoulos KA. Pericardial involvement as an atypical manifestation of giant cell arteritis: report of a clinical case and literature review. Am J Med Sci 2006; 332:198-204. [PMID: 17031245 DOI: 10.1097/00000441-200610000-00007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pericardial effusion has been known to be a rare manifestation of giant cell arteritis. During the last six decades, only 24 cases have been cited in the literature. In this report, we describe the case of a patient presenting with nonspecific symptoms and development of pericardial effusion. PROCEDURES AND FINDINGS A 71-year-old woman was admitted to the hospital with low-grade fever, exertion breathlessness, atypical diffuse muscular pain, and weight loss over a period of about 5 weeks. Pericardial effusion and giant cell arteritis were diagnosed by echocardiography and left temporal artery biopsy, respectively. Treatment with corticosteroids resulted in remarkable improvement of symptoms and complete remission of pericardial effusion. One year after admission, the patient remained in a stable good condition, under low steroid maintenance dosage. CONCLUSIONS The diversity of clinical manifestations (such as pericardial effusion) in such a potentially severe disease should alert the physician to prompt diagnosis and treatment in view of impending irreparable vascular damages, even in cases in which the initial presentation is quite uncommon.
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Affiliation(s)
- George D Bablekos
- Department of Experimental Physiology, Clinical Unit, Faculty of Medicine, University of Ioannina, Ioannina, Greece.
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49
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Sulli A, Montecucco CM, Caporali R, Cavagna L, Montagna P, Capellino S, Fazzuoli L, Seriolo B, Alessandro C, Secchi ME, Cutolo M. Glucocorticoid Effects on Adrenal Steroids and Cytokine Responsiveness in Polymyalgia Rheumatica and Elderly Onset Rheumatoid Arthritis. Ann N Y Acad Sci 2006; 1069:307-14. [PMID: 16855158 DOI: 10.1196/annals.1351.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Polymyalgia rheumatica (PMR) usually exhibits a good clinical response to glucocorticoid (GC) treatment, but early clinical symptoms may create some difficulties in the differential diagnosis with elderly onset rheumatoid arthritis (EORA), particularly in patients complaining of shoulder and pelvic girdle involvement at onset (PMR-like clinical onset) (EORA/PMR). Since neuroendocrine mechanisms seem to play a pathogenetic role in these clinical conditions, the aim of this study was to evaluate hormone and cytokine responsiveness to GC treatment in these patients. Cortisol (CO), dehydroepiandrosterone sulphate (DHEAS), 17-OH-progesterone (PRG), interleukin-1 receptor antagonist (IL-1Ra), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) were evaluated at base line, and 1 month after GC treatment (prednisone 10 mg/day), in 14 PMR, 11 EORA/PMR, and 13 EORA patients (mean age 73 +/- 5 years, +/- SD, mean disease duration 3 +/- 2 months, +/- SD). No patient was taking GCs or immunosuppressive agents at base line. Following GC treatment, CO, DHEAS, and PRG decreased significantly in both PMR and EORA/PMR patients (P < 0.05), but not in EORA patients. On the contrary, IL-1Ra was significantly increased in both PMR and EORA/PMR patients (P < 0.05). IL-6 and TNF-alpha serum levels were significantly decreased in all groups of patients (P < 0.05). In conclusion, PMR and EORA/PMR seem to exhibit similar hormonal variations after GC administration, when compared to EORA patients. These differences suggest a deficient function of the hypothalamic-pituitary-adrenal (HPA) axis in PMR and EORA/PMR patients, with a related higher responsiveness to GC treatment. Interestingly, in PMR and EORA/PMR patients, GC treatment was found to downregulate PRG serum levels.
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Affiliation(s)
- Alberto Sulli
- Research Laboratory and Division of Rheumatology, Department of Internal Medicine, San Martino Hospital, University of Genova, Viale Benedetto XV, 6-16132 Genova, Italy.
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Cutolo M, Montecucco CM, Cavagna L, Caporali R, Capellino S, Montagna P, Fazzuoli L, Villaggio B, Seriolo B, Sulli A. Serum cytokines and steroidal hormones in polymyalgia rheumatica and elderly-onset rheumatoid arthritis. Ann Rheum Dis 2006; 65:1438-43. [PMID: 16644782 PMCID: PMC1798362 DOI: 10.1136/ard.2006.051979] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Polymyalgia rheumatica (PMR) may create some difficulties in the differential diagnosis of elderly-onset rheumatoid arthritis (EORA) and of EORA with PMR-like onset (EORA/PMR). AIM To investigate possible differences between three groups of patients, with regard to serum levels of inflammatory cytokines and steroidal hormones at baseline and after 1 month of treatment with glucocorticoids (prednisone 7.5-12.5 mg/day). PATIENTS AND METHODS 14 patients with PMR, 15 with EORA and 14 with EORA/PMR, as well as 15 healthy, matched controls were analysed. Tumour necrosis factor alpha (TNFalpha), interleukin (IL)6, IL1 receptor antagonist (IL1Ra), cortisol, dehydroepiandrosterone sulphate (DHEAS) and 17-hydroxy-progesterone (PRG) were evaluated. RESULTS Serum levels of both TNFalpha and IL6 were significantly higher in all three groups of patients than in controls (p<0.01). Serum IL6 levels were significantly higher in patients with both PMR and EORA/PMR than in patients with EORA (p<0.05). IL1Ra serum levels were significantly higher in patients with EORA than in controls (p<0.001) and in patients with PMR and EORA/PMR (p<0.05). DHEAS was significantly lower in patients with EORA/PMR than in those with EORA (p<0.05). PRG was significantly higher in all patient groups (p<0.05). After glucocorticoid treatment, serum TNFalpha and IL6 levels significantly decreased in all patient groups; IL1Ra significantly increased in patients with PMR and in those with EORA/PMR; cortisol, DHEAS, and PRG significantly decreased in patients with PMR and in those with EORA/PMR (p<0.05). CONCLUSIONS Different cytokine and steroidal hormone patterns suggest that patients with PMR and those with EORA/PMR seem to be have a more intensive inflammatory reaction and are more efficient responders to glucocorticoid treatment than patients with EORA.
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Affiliation(s)
- M Cutolo
- Department of Internal Medicine, Research Laboratory and Division of Rheumatology, University Hospital San Martino, Viale Benedetto XV no 6, 16132 Genova, Italy.
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