Raised ESR in polymyalgia rheumatica no longer a sine qua non?

Polymyalgia rheumatica: 125 years of epidemiological progress?

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 epidemiology of this disease and whether such studies have advanced our knowledge of its aetiopathogenesis and management.

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 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.

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 investigating the populations susceptible, the geographic distribution of these affected populations and the associated sociological and genetic elements that might contribute to its occurrence, polymyalgia rheumatica remains a difficult problem for the public health services of the developed world.

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. Until then, clear guidelines on the future incidence and prevalence of polymyalgia rheumatica and the public health problems of the disease and its management, especially in relation to the use of long term corticosteroids, will be difficult to provide.

Polymyalgia rheumatica: 125 years of progress?

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.

Optimal management of giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are clinical diagnoses without “gold standard” serological or histological tests, excluding temporal artery biopsy for GCA. Further, other conditions may mimic GCA and PMR. Treatment with 10–20 mg of prednisolone daily is suggested for PMR or 40–60 mg daily for GCA when temporal arteritis is suspected. This ocular involvement of GCA should be treated as a medical emergency to prevent possible blindness and steroids should be commenced immediately. There are no absolute guidelines as to the dose or duration of administration; the therapeutics of treating this condition and the rate of reduction of prednisolone should be adjusted depending on the individual’s response and with consideration of the multiple risks of high-dose and long-term glucocorticoids. Optimal management may need to consider the role of low-dose aspirin in reducing complications. Clinicians should also be aware of studies that indicate an increased incidence of large-artery complications with GCA. This clinical area requires further research through future development of radiological imaging to aid the diagnosis and produce a clearer consensus relating to diagnosis and treatment.

[Rhizomelic pseudopolyarthritis: update]

PURPOSE

Update of recent works on polymyalgia rheumatica (PMR). CURRENT KNOWLEDGE ANS KEY POINTS: In polymyalgia rheumatica (PMR) unassociated with giant cell arteritis (GCA) (twice as frequent as GCA without PMR) several recent works demonstrated by MRI or echography that synovitis and/or subacromial bursitis accounted for most of the painful shoulders and could be relieved by steroid injections. Peripheral synovitis can also occur in 10-20% of PMR, and lead to consideration of other diagnoses, mostly RA or the RS3PE syndromes for those cases of PMR with peripheral edema. PMR with asymmetrical onset are often difficult to diagnose early, and the classification criteria for PMR are not widely accepted. When clinical signs suggestive of GCA are lacking, temporal biopsy is positive in only 1 to 5% of PMR cases. Several studies on PMR with so-called 'normal' ESR (below 30 mm, first hour) have cast doubts on the value of this biological sign (although 'normal ESR' should only stand for values below 11 mm). Hence it would be worthwhile to study whether CRP and even SAA deserve to be added to future sets of criteria for PMR. A defect in hypothalamic axis response is often noticed and could play a part in PMR pathogenesis, thus explaining why PMR is quite exclusively noticed after ages 50 or 60. Two-thirds of patients can stop prednisone within 2 years after the onset of treatment. The lack of a prompt response within the first days should suggest differential diagnoses, including some myelodysplastic disorders.

FUTURE PROSPECTS AND PROJECTS

The search for genetic factors common or specific to PMR and GCA could enhance our understanding of these overlapping syndromes. Studies of the transcriptosomes of lymphocytes infiltrating the target tissues (arterial wall in GCA, synovium in PMR) might also prove informative. Controlled studies of new biological treatments like cytokine inhibitors (anti-TNF-alpha, anti-interferon gamma) could demonstrate a clear sparing effect in steroids, a goal not yet achieved by the use of current DMARDs, including MTX.