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Wendling D, Al Tabaa O, Chevet B, Fakih O, Ghossan R, Hecquet S, Dernis E, Maheu E, Saraux A, Besson FL, Alegria GC, Cortet B, Fautrel B, Felten R, Morel J, Ottaviani S, Querellou-Lefranc S, Ramon A, Ruyssen-Witrand A, Seror R, Tournadre A, Foulquier N, Verlhac B, Verhoeven F, Devauchelle-Pensec V. Recommendations of the French Society of Rheumatology for the management in current practice of patients with polymyalgia rheumatica. Joint Bone Spine 2024; 91:105730. [PMID: 38583691 DOI: 10.1016/j.jbspin.2024.105730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To develop recommendations for the routine management of patients with polymyalgia rheumatica (PMR). METHODS Following standard procedures, a systematic review of the literature by five supervised junior rheumatologists, based on the questions selected by the steering committee (5 senior rheumatologists), was used as the basis for working meetings, followed by a one-day plenary meeting with the working group (15 members), leading to the development of the wording and determination of the strength of the recommendations and the level of agreement of the experts. RESULTS Five general principles and 19 recommendations were drawn up. Three recommendations relate to diagnosis and the use of imaging, and five to the assessment of the disease, its activity and comorbidities. Non-pharmacological therapies are the subject of one recommendation. Three recommendations concern initial treatment based on general corticosteroid therapy, five concern the reduction of corticosteroid therapy and follow-up, and two concern corticosteroid dependence and steroid-sparing treatments (anti-IL-6). CONCLUSION These recommendations take account of current data on PMR, with the aim of reducing exposure to corticosteroid therapy and its side effects in a fragile population. They are intended to be practical, to help practitioners in the day-to-day management of patients with PMR.
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Affiliation(s)
- Daniel Wendling
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France.
| | - Omar Al Tabaa
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France; Rhumatologie, Hôpital NOVO, Pontoise, France
| | - Baptiste Chevet
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Olivier Fakih
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Roba Ghossan
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France
| | | | | | - Emmanuel Maheu
- Service de rhumatologie, Hôpital St Antoine, AP-HP, et cabinet médical, Paris, France
| | - Alain Saraux
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Florent L Besson
- Service de médecine nucléaire-imagerie moléculaire, Hôpitaux universitaires Paris-Saclay AP-HP, CHU Bicêtre, DMU SMART IMAGING, Le Kremlin-Bicêtre, France
| | | | - Bernard Cortet
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | - Bruno Fautrel
- Service de rhumatologie, GH Pitié Salpêtrière, AP-HP.Sorbonne Université, INSERM UMRS 1136-5, Réseau de recherche clinique CRI-IMIDIATE, 75013 Paris, France
| | - Renaud Felten
- Service de rhumatologie et centre d'investigation clinique 1434, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jacques Morel
- Service de rhumatologie. CHU et Université de Montpellier, Montpellier, France
| | | | - Solène Querellou-Lefranc
- Nuclear Medicine department, University Hospital, Brest, France, University of Western Brittany (UBO), Brest, France, Inserm, University of Brest, CHRU Brest, UMR 1304, GETBO, Brest cedex, France
| | - André Ramon
- Service de rhumatologie, CHU Dijon Bourgogne, Dijon, France
| | - Adeline Ruyssen-Witrand
- Centre de rhumatologie, CHU de Toulouse, Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS « Pharmacologie En Population cohorteS et biobanqueS », Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Raphaèle Seror
- Service de rhumatologie, CHU Kremlin-Bicetre, AP-HP, Paris, France
| | - Anne Tournadre
- Rhumatologie CHU Clermont-Ferrand, Université Clermont Auvergne INRAe, Clermont-Ferrand, France
| | - Nathan Foulquier
- LBAI, UMR1227, University of Brest, Inserm, CHU de Brest, Brest, France
| | | | - Frank Verhoeven
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Valérie Devauchelle-Pensec
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France.
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Allard B, Devauchelle-Pensec V, Saraux A, Nowak E, Tison A, Boukhlal S, Guellec D, Jousse-Joulin S, Cornec D, Marhadour T, Le Pennec R, Salaün PY, Querellou S. [ 18F]FDG PET/CT for therapeutic assessment of Abatacept in early-onset polymyalgia rheumatica. Eur J Nucl Med Mol Imaging 2024; 51:1297-1309. [PMID: 38095675 DOI: 10.1007/s00259-023-06557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/01/2023] [Indexed: 03/22/2024]
Abstract
PURPOSE Evaluate the benefit of 2-deoxy-2-[18F]-fluoro-D-glucose ([18F] FDG) positron emission tomography/computed tomography (PET/CT) for the therapeutic assessment of Abatacept (ABA) as first-line therapy in early-onset polymyalgia rheumatica (PMR) patients. METHODS This was an ancillary study of ALORS trial (Abatacept in earLy Onset polymyalgia Rheumatica Study) assessing the ability of ABA versus placebo to achieve low disease activity (C-Reactive Protein PMR activity score (CRP PMR-AS) ≤ to 10) without glucocorticoid (GC) at week 12 in patients with early-onset PMR. The patients underwent [18F] FDG PET/CT at baseline and after 12 weeks of treatment. Responses to treatments were evaluated according to CRP PMR-AS, Erythrocyte Sedimentation Rate (ESR) PMR-AS, Clin PMR-AS, and CRP-Imputed (Imput-CRP) PMR-AS. Quantitative score by maximal standardized uptake value (SUVmax) and combined qualitative scores according to liver uptake (Leuven, Leuven/Groningen, and Besançon Scores) were used for assessment of [18F] FDG uptake in regions of interest (ROI) usually affected in PMR. Student's t-test was applied to evaluate the clinical, biological, and [18F] FDG uptake variation difference in ABA and placebo groups between W0 and W12. Subgroup analysis by GC rescue was performed. RESULTS At W12, there was no significant difference according to SUVmax between the ABA and the placebo groups in all ROI. Subgroup analysis according to GC administration demonstrated a significant (p 0.047) decrease in SUVmax within the left sternoclavicular joint ROI in the ABA group (- 0.8) compared to the placebo group (+ 0.6) without GC rescue. Other results did not reveal any significant difference between the ABA and placebo groups. According to combined qualitative scores, there was no significant difference between ABA and placebo groups for the direct comparison analysis and subgroup analysis according to GC rescue. CONCLUSION [18F] FDG PET/CT uptake did not decrease significantly after ABA compared to placebo in anatomical areas usually affected in PMR patients. These results are correlated with the clinical-biological therapeutic assessment. CLINICAL TRIAL REGISTRATION The study was approved by the appropriate ethics committee (CPP Sud-Est II Ref CPP: 2018-33), and all patients gave their written informed consent before study enrollment. The protocol was registered on Clinicaltrials.gov (NCT03632187).
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Affiliation(s)
- Bastien Allard
- Nuclear Medicine Department, University Hospital, Brest, France
- University of Western Brittany (UBO), Brest, France
| | - Valérie Devauchelle-Pensec
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Alain Saraux
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Emmanuel Nowak
- Clinical Research and Innovation Department (DRCI), INSERM CIC 0502, Brest University Hospital, Brest, France
| | - Alice Tison
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Sara Boukhlal
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Dewi Guellec
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Sandrine Jousse-Joulin
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Divi Cornec
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Thierry Marhadour
- University of Western Brittany (UBO), Brest, France
- Department of Rheumatology, Brest University Hospital, Brest, France
- INSERM (U1227), LabEx IGO, Brest University, Brest, France
| | - Romain Le Pennec
- Nuclear Medicine Department, University Hospital, Brest, France
- University of Western Brittany (UBO), Brest, France
- UMR 1304, Inserm, Univ Brest, CHRU, GETBO, Brest Cedex, France
| | - Pierre-Yves Salaün
- Nuclear Medicine Department, University Hospital, Brest, France
- University of Western Brittany (UBO), Brest, France
- UMR 1304, Inserm, Univ Brest, CHRU, GETBO, Brest Cedex, France
| | - Solène Querellou
- Nuclear Medicine Department, University Hospital, Brest, France.
- University of Western Brittany (UBO), Brest, France.
- UMR 1304, Inserm, Univ Brest, CHRU, GETBO, Brest Cedex, France.
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D'Agostino J, Souki A, Lohse A, Carvajal Alegria G, Dernis E, Richez C, Truchetet ME, Wendling D, Toussirot E, Perdriger A, Gottenberg JE, Felten R, Fautrel B, Chiche L, Hilliquin P, Le Henaff C, Dervieux B, Direz G, Chary-Valckenaere I, Cornec D, Guellec D, Marhadour T, Nowak E, Saraux A, Devauchelle-Pensec V. Concordance and agreement between different activity scores in polymyalgia rheumatica. RMD Open 2024; 10:e003741. [PMID: 38490696 PMCID: PMC10946364 DOI: 10.1136/rmdopen-2023-003741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/27/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVE The C reactive protein polymyalgia rheumatica activity score (CRP-PMR-AS) is a composite index that includes CRP levels and was developed specifically for PMR. As treatments such as interleukin-6 antagonists can normalise CRP levels, the erythrocyte sedimentation rate (ESR) of PMR-AS, the clinical (clin)-PMR-AS and the imputed-CRP (imp-CRP)-PMR-AS have been developed to avoid such bias. Our primary objective was to measure the correlation of these activity scores. Our secondary objective was to evaluate the concordance between different cutoffs of the PMR-ASs. METHOD Data from the Safety and Efficacy of tocilizumab versus Placebo in Polymyalgia rHeumatica With glucocORticoid dEpendence (SEMAPHORE) trial, a superiority randomised double-blind placebo-controlled trial, were subjected to post hoc analysis to compare the efficacy of tocilizumab versus placebo in patients with active PMR. The CRP-PMR-AS, ESR-PMR-AS, clin-PMR-AS and imp-CRP-PMR-AS were measured at every visit. The concordance and correlation between these scores were evaluated using kappa correlation coefficients, Bland-Altman correlations, intraclass correlation coefficients (ICCs) and scatter plots. RESULTS A total of 101 patients were included in the SEMAPHORE trial, and 100 were analysed in this study. The correlation between the PMR-ASs was excellent, as the ICC and kappa were >0.85 from week 4 until week 24 (CRP-PMR-AS ≤10 or >10). Bland-Altman plots revealed that the differences between the CRP-PMR-AS and the other threescores were low. The cut-off values for the clin-PMR-AS were similar to those for the CRP-PMR-AS 86% of the time. CONCLUSION The correlation between all the PMR-ASs was excellent, reflecting the low weight of CRP. In clinical trials using drugs that have an impact on CRP, the derived activity scores can be used. TRIAL REGISTRATION NUMBER NTC02908217.
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Affiliation(s)
- Justine D'Agostino
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Aghiles Souki
- Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Anne Lohse
- Hopital Nord Franche-Comte-Site de Belfort, Belfort, France
| | | | - Emanuelle Dernis
- Department of Rheumatology, Centre Hospitalier Le Mans, Le Mans, France
| | - Christophe Richez
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
- UMR CNRS 5164, Université de Bordeaux Collège Sciences de la Santé, Bordeaux, France
| | - Marie-Elise Truchetet
- Department of Rheumatology, Centre Hospitalier Universitaire de Bordeaux Groupe Hospitalier Pellegrin, Bordeaux, France
| | - Daniel Wendling
- Rheumatology and EA4266 Franche-Comté University, Centre Hospitalier Universitaire de Besancon, Besancon, France
| | - Eric Toussirot
- INSERM Clinical Investigation Center 1431, Centre Hospitalier Universitaire de Besancon, Besancon, France
- Department of Rheumatology, Centre Hospitalier Universitaire de Besancon, Besancon, France
| | - Aleth Perdriger
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Jacques-Eric Gottenberg
- Department of Rheumatology, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Renaud Felten
- Department of Rheumatology, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Bruno Fautrel
- Department of Rheumatology, Assistance Publique-Hopitaux de Paris, Paris, France
- INSERM UMR-S 1136, Pierre Louis Epidemiology and Public Health Research Institute, Paris, France
| | - Laurent Chiche
- Internal Medicine, Marseille Public University Hospital System, Marseille, France
| | - Pascal Hilliquin
- Department of Rhumatology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Catherine Le Henaff
- Department of Rheumatology, Pays de Morlaix Hospital Centre, Morlaix, France
| | - Benjamin Dervieux
- Department of Rhuamtology, GHR Mulhouse Sud Alsace, Mulhouse, France
| | - Guillaume Direz
- Department of Rheumatology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Divi Cornec
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
- INSERM 1227, Université de Bretagne Occidentale, Brest, France
| | - Dewi Guellec
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
- INSERM Clinical Investigations Centre 1412, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Thierry Marhadour
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Emmanuel Nowak
- Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Centre Hospitalier Universitaire de Brest, Brest, France
- Centre Hospitalier Universitaire de Brest, Brest, INSERM Clinical Investigations Centre (CIC) 1412, France
| | - Alain Saraux
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
- INSERM 1227, Université de Bretagne Occidentale, Brest, France
| | - Valérie Devauchelle-Pensec
- Department of Rheumatology, Centre Hospitalier Universitaire de Brest, Brest, France
- INSERM 1227, Université de Bretagne Occidentale, Brest, France
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Saraux A, Le Henaff C, Dernis E, Carvajal-Alegria G, Tison A, Quere B, Petit H, Felten R, Jousse-Joulin S, Guellec D, Marhadour T, Kervarrec P, Cornec D, Querellou S, Nowak E, Souki A, Devauchelle-Pensec V. Abatacept in early polymyalgia rheumatica (ALORS): a proof-of-concept, randomised, placebo-controlled, parallel-group trial. THE LANCET. RHEUMATOLOGY 2023; 5:e728-e735. [PMID: 38251563 DOI: 10.1016/s2665-9913(23)00246-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Medium-dose glucocorticoids can improve symptoms in nearly all patients with polymyalgia rheumatica. According to its good safety profile, abatacept could be used instead of glucocorticoids in early polymyalgia rheumatica. We aimed to determine whether the efficacy of abatacept is sufficient to justify larger studies in early polymyalgia rheumatica. METHODS To evaluate whether abatacept allows low disease activity without glucocorticoids in early polymyalgia rheumatica, we conducted a proof-of-concept, randomised, double-blind, placebo-controlled, parallel-group trial. Participants were recruited from five centres in France (in Brest, Le Mans, Morlaix, Dinan and Saint Malo, and Strasbourg) and were included if they had recent-onset (<6 months) polymyalgia rheumatica with a C-reactive protein (CRP) polymyalgia rheumatica activity score (PMR-AS) of more than 17 without any signs or symptoms of giant cell arteritis (clinical and [18F]fluorodeoxyglucose PET-CT evaluation). Participants were randomly assigned (1:1) to receive weekly subcutaneous abatacept (125 mg) or matching placebo, with glucocorticoid rescue therapy allowed in cases of high disease activity, for 12 weeks, and then glucocorticoid treatment based on disease activity, until week 36. Investigators, patients, outcome assessors, and sponsor personnel were masked to group assignments. The primary endpoint was low disease activity (CRP PMR-AS ≤10) at week 12 without glucocorticoids and without rescue treatment. The study was powered to demonstrate a 60% difference in response rates between groups. Open-ended adverse events were collected at each visit by clinicians and were categorised following system organ class classification after study completion. The ALORS trial is registered with ClinicalTrials.gov, NCT03632187. FINDINGS 34 patients (22 women and 12 men) were randomly assigned between Dec 13, 2018, and Oct 21, 2021. All patients who had been randomly assigned were included in the analysis. The primary endpoint was reached by eight (50%) of 16 patients in the abatacept group and four (22%) of 18 patients in the placebo group (relative risk 2·2 [0·9-5·5]); crude p=0·15; adjusted p=0·070). Eight (50%) patients in the abatacept and 15 (83%) in the placebo group had adverse events. Four patients (one [6%] in the abatacept group and three [17%] in the placebo group) had serious adverse events. There were no deaths or new safety concerns. INTERPRETATION This study suggests that the effect of abatacept alone is not strong enough to justify larger studies in early polymyalgia rheumatica. This is only a first step in deciding whether a larger study should be conducted in early polymyalgia rheumatica and does not exclude a potential effect of abatacept in glucocorticoid-dependent polymyalgia rheumatica. FUNDING BMS Pharma France.
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Affiliation(s)
- Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France; Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France.
| | | | | | | | - Alice Tison
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Baptiste Quere
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Hélène Petit
- Service de rhumatologie, Groupement Hospitalier Rance Emeraude, CH de Dinan, Dinan, France
| | - Renaud Felten
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Sandrine Jousse-Joulin
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Dewi Guellec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Thierry Marhadour
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Patrice Kervarrec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Divi Cornec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Solene Querellou
- Department of Nuclear Medicine, Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM, GETBO, Brest, France
| | - Emmanuel Nowak
- Clinical Research and Innovation Department (DRCI), INSERM, CHU Brest, Brest, France; Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
| | - Aghiles Souki
- Clinical Research and Innovation Department (DRCI), INSERM, CHU Brest, Brest, France; Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
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Bolhuis TE, Marsman DE, den Broeder AA, den Broeder N, van der Maas A. 1-year results of treatment with rituximab in polymyalgia rheumatica: an extension study of a randomised double-blind placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2023; 5:e208-e214. [PMID: 38251523 DOI: 10.1016/s2665-9913(23)00032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Rituximab was effective for patients with polymyalgia rheumatica in the 21-week BRIDGE-PMR randomised controlled trial. Here, we aimed to assess rates of glucocorticoid-free remission up to 1 year after infusion in an extension of this trial. METHODS BRIDGE-PMR was a randomised controlled proof-of-concept trial that enrolled participants with polymyalgia rheumatica according to 2012 European League Against Rheumatism-American College of Rheumatology classification criteria at the Sint Maartenskliniek, Nijmegen, Netherlands. Patients were randomly allocated in a 1:1 ratio to receive one intravenous dose of 1000 mg rituximab or placebo, with identical pre-medication and accelerated glucocorticoid tapering over 17 weeks. After the 21-week study, patients were followed in a double-blind extension until 1 year after infusion during which standard-of-care treatment was provided. The primary outcome after 52 weeks was between-group difference in glucocorticoid-free remission (ie, polymyalgia rheumatica activity score [PMR-AS] <10), assessed in all randomly allocated participants, with data imputed using a predictive mean matching model (provided data were missing at random). A sensitivity analysis restricted to patients with complete data (complete case analysis) was also done. This trial is registered with EudraCT (2018-002641-11) and the Dutch trial database (NL7414). FINDINGS Between Dec 18, 2019 and June 8, 2021, 47 patients enrolled in the BRIDGE-PMR were followed up in this extension study (23 [11 women and 12 men] allocated rituximab and 24 [13 women and 11 men] allocated placebo), of who 38 had recently diagnosed polymyalgia rheumatica and nine had relapsing polymyalgia rheumatica. Mean (SD) age was 64 (10) years in the rituximab group and 66 (9) years in the placebo group. All participants were White. Missing data were imputed for six participants (four rituximab, two placebo); because the data were probably missing at random, a complete case analysis was added as sensitivity analyses. In the imputed analysis, the between-group absolute difference reached statistical significance (12 [52%] of 23 in the rituximab group in glucocorticoid-free remission vs five [21%] of 24 participants in the placebo group; absolute difference 31% [95% CI 5 to 57], RR 2·5 [1·0 to 6·0]; p=0·04). In the complete case analysis, nine (47%) of 19 patients in the rituximab group were in glucocorticoid-free remission 1 year after infusion compared with five (23%) of 22 in the placebo group (absolute difference 25% [95% CI -4 to 53], relative risk (RR) 2·1 [95% CI 0·8 to 5·2]; p=0·12). Eight (33%) patients in the placebo group and six (26%) in the rituximab group had adverse events. INTERPRETATION After a single dose of rituximab (1000 mg), the proportion of patients with polymyalgia rheumatica in glucocorticoid-free remission remained stable at 1 year after infusion, and a glucocorticoid sparing effect was evident. A larger trial including possibility for retreatment is warranted to confirm these results. FUNDING Sint Maartenskliniek.
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Affiliation(s)
- Thomas E Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Diane E Marsman
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands.
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Devauchelle-Pensec V, Carvajal-Alegria G, Dernis E, Richez C, Truchetet ME, Wendling D, Toussirot E, Perdriger A, Gottenberg JE, Felten R, Fautrel BJ, Chiche L, Hilliquin P, Le Henaff C, Dervieux B, Direz G, Chary-Valckenaere I, Cornec D, Guellec D, Marhadour T, Nowak E, Saraux A. Effect of Tocilizumab on Disease Activity in Patients With Active Polymyalgia Rheumatica Receiving Glucocorticoid Therapy: A Randomized Clinical Trial. JAMA 2022; 328:1053-1062. [PMID: 36125471 DOI: 10.1001/jama.2022.15459] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Few treatments are available for patients with glucocorticoid-dependent polymyalgia rheumatica. IL-6 antagonists may reduce disease activity in patients with active glucocorticoid-dependent polymyalgia rheumatica. OBJECTIVE To compare the efficacy of tocilizumab vs placebo in patients with glucocorticoid-dependent polymyalgia rheumatica. DESIGN, SETTING, AND PARTICIPANTS This double-blind, parallel-group, placebo-controlled randomized clinical trial enrolled 101 patients with polymyalgia rheumatica at 17 hospitals in France from February 2017 to October 2019. Final follow-up occurred in November 2020. Inclusion criteria were persistent disease activity (polymyalgia rheumatica activity score computed using the C-reactive protein level [CRP PMR-AS] >10) and prednisone dose greater than or equal to 10 mg per day. INTERVENTIONS Patients were randomly assigned to receive intravenous tocilizumab (8 mg/kg; n = 51) or placebo (n = 50) every 4 weeks for 24 weeks, combined with predefined standardized tapering of oral prednisone. MAIN OUTCOMES AND MEASURES The primary efficacy end point was CRP PMR-AS less than 10 (range, 0-100; higher values indicate greater activity; no minimal clinically important difference defined) combined with either prednisone dose less than or equal to 5 mg per day or a decrease in prednisone dose greater than or equal to 10 mg from baseline at week 24. There were 11 secondary outcomes assessed at week 24 included in this report, including disease activity (measured by CRP PMR-AS) and the proportion of patients no longer taking prednisone. RESULTS Of the 101 randomized patients (mean age, 67.2 years; 68 [67.3%] women), 100 (99%) received at least 1 infusion and 100 completed the trial. The primary end point was achieved in 67.3% of patients in the tocilizumab group and 31.4% of patients in the placebo group (adjusted difference, 36.0% [95% CI, 19.4%-52.6%]; adjusted relative risk, 2.3 [95% CI, 1.5-3.6]; P < .001). Of 11 reported secondary end points at 24 weeks, 7 showed significant differences favoring tocilizumab, including mean CRP PMR-AS score (7.5 [95% CI, 5.4-9.6] vs 14.9 [95% CI, 11.4-18.4]; adjusted difference, -7.5 [95% CI, -11.2 to -3.8]; P < .001) and the percentage of patients no longer receiving prednisone (49.0% vs 19.6%; adjusted difference, 29.3% [95% CI, 18.9%-39.7%]; adjusted relative risk, 2.5 [95% CI, 1.8-3.5]; P < .001). The most frequent adverse events were infections, experienced by 23 patients (46.9%) in the tocilizumab group and 20 (39.2%) in the placebo group. CONCLUSIONS AND RELEVANCE Among patients with active polymyalgia rheumatica despite prednisone therapy, tocilizumab, compared with placebo, resulted in a significantly greater percentage of patients with a CRP PMR-AS less than 10 with reduced prednisone requirements at week 24. Further research is needed to confirm efficacy and to determine the balance of potential benefits and harms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02908217.
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Affiliation(s)
- Valérie Devauchelle-Pensec
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | - Guillermo Carvajal-Alegria
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | | | - Christophe Richez
- Rheumatology Department, Bordeaux University Hospital and Bordeaux University, Bordeaux, France
| | - Marie-Elise Truchetet
- Rheumatology Department, Bordeaux University Hospital and Bordeaux University, Bordeaux, France
| | - Daniel Wendling
- Rheumatology Department, Besançon Regional University Hospital and Bourgogne Franche-Comté University, Besançon, France
| | - Eric Toussirot
- INSERM CIC-1431 Clinical Investigations Center, Besançon University Hospital Besançon, France
| | - Aleth Perdriger
- Rennes 1 University, School of Medicine, South Hospital, Rheumatology Department, Rennes, France
| | | | - Renaud Felten
- Department of Rheumatology, Strasbourg University Hospitals, Strasbourg, France
| | - Bruno Jean Fautrel
- Sorbonne Université - Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière Hospital, Rheumatology Department, Paris, France
| | - Laurent Chiche
- Internal Medicine Department, European Hospital, Marseille, France
| | - Pascal Hilliquin
- Department of Rheumatology, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | | | | | - Guillaume Direz
- Rheumatology Department, Community Hospital, Le Mans, France
| | | | - Divi Cornec
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | - Dewi Guellec
- Clinical Investigations Centre (CIC) 1412, National Health and Medical Research Institute (INSERM), Brest, France
| | | | - Emmanuel Nowak
- Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
| | - Alain Saraux
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
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Yu Y, Ye A, Chen C, Dai W, Liu X. The impact of family doctor system on patients' utilisation of general practitioner in primary care facilities-Evidence from Hangzhou, China. Int J Health Plann Manage 2022; 37:3089-3102. [PMID: 35801256 DOI: 10.1002/hpm.3540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 02/03/2022] [Accepted: 06/22/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aims to examine whether participating in the contracted family doctor system increases patients' utilisation of primary care general practitioner for multiple disease outcomes in China. METHODS Binary logistic regression models were estimated using data collected from 372 community residents in nine selected districts of Hangzhou, China. RESULTS Findings revealed that (1) for patients with influenza, diabetes, upper respiratory infection, and gingivitis, those who participated in the contracted family doctor system were approximately 4.3 times, 98.4%, 92.5%, and 52.8% more likely to choose primary care general practitioners (GP) for their initial diagnosis, respectively, as compared with their counterparts who did not have contracted family doctors; (2) For patients with stroke or cerebrovascular disease and cholecystitis or cholelithiasis, those who had contracted family doctors were 1.111 times and 80.6% more likely to choose primary care GP for their subsequent disease maintenance, respectively, as compared to their counterparts without contracted family doctors. CONCLUSION Our findings indicate that the contracted family doctor system not only increases the utilisation of primary care GP for patients with many chronic conditions but also promotes the overall completion of China's hierarchical medical system in the long run. Policy implications were provided to help policymakers actively construct and develop the contracted family doctor system to promote the hierarchical medical system in China.
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Affiliation(s)
- Yang Yu
- School of Urban and Environmental Science, Central China Normal University, Wuhan, Hubei, China
| | - Aizhen Ye
- School of Data Sciences, Zhejiang University of Finance and Economics, Hangzhou, Zhejiang, China
| | - Cen Chen
- School of Public Administration, Zhejiang University of Finance and Economics, Hangzhou, Zhejiang, China
| | - Weidong Dai
- School of Public Administration, Zhejiang University of Finance and Economics, Hangzhou, Zhejiang, China
| | - Xu Liu
- School of Public Administration, Zhejiang University of Finance and Economics, Hangzhou, Zhejiang, China
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Marsman DE, Bolhuis TE, den Broeder N, den Broeder AA, van der Maas A. PolyMyalgia Rheumatica treatment with Methotrexate in Optimal Dose in an Early disease phase (PMR MODE): study protocol for a multicenter double-blind placebo controlled trial. Trials 2022; 23:318. [PMID: 35428320 PMCID: PMC9012047 DOI: 10.1186/s13063-022-06263-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease affecting people older than 50, resulting in pain and stiffness of the neck, shoulder, and pelvic girdle. To date, glucocorticoids (GC) remain the cornerstone of treatment, but these have several drawbacks. Firstly, a large proportion of patients do not achieve GC-free remission within either the first (over 70%) or second year of treatment (over 50%). Secondly, GC-related adverse events (AE) occur in up to 65% of patients and can be severe. The current EULAR/ACR guidelines for PMR recommend early introduction of methotrexate (MTX) as a GC sparing agent in patients at risk for worse prognosis. However, earlier trials of low to medium quality only studied MTX dosages of 7.5–10 mg/week with no to modest effect. These doses may be suboptimal as MTX is recommended in higher doses (25 mg/week) for other inflammatory rheumatic diseases. The exact role, timing, and dose of MTX in PMR remain unclear, and therefore, our objective is to study the efficacy of MTX 25 mg/week in recently diagnosed PMR patients. Methods We set up a double-blind, randomized, placebo-controlled superiority trial (PMR MODE) to assess the efficacy of MTX 25 mg/week versus placebo in a 1:1 ratio in 100 recently diagnosed PMR patients according to the 2012 EULAR/ACR criteria. All patients will receive prednisolone 15 mg/day, tapered to 0 mg over the course of 24 weeks. In case of primary non-response or disease relapse, prednisolone dose will be temporarily increased. Assessments will take place at baseline, 4, 12, 24, 32, and 52 weeks. The primary outcome is the difference in proportion of patients in GC-free remission at week 52. Discussion No relapsing PMR patients were chosen, since the possible benefits of MTX may not outweigh the risks at low doses and effect modification may occur. Accelerated tapering was chosen in order to more easily identify a GC-sparing effect if one exists. A composite endpoint of GC-free remission was chosen as a clinically relevant endpoint for both patients and rheumatologist and may reduce second order (treatment) effects. Trial registration Dutch Trial Registration, NL8366. Registered on 10 February 2020
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Bolhuis TE, Nizet LE, Owen C, den Broeder AA, van den Ende CH, van der Maas A. Measurement properties of the PolyMyalgia Rheumatica Activity Score (PMR-AS): a systematic literature review. J Rheumatol 2022; 49:627-634. [DOI: 10.3899/jrheum.211292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
Objective To perform a COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) based Systematic Literature Review of measurement properties of the Polymyalgia Rheumatica Activity Score (PMR-AS). Methods Pubmed, EMBASE, and CINAHL were broadly searched. English full text articles, with (quantitative) data on at least 5 PMR patients using the PMR-AS were selected. Seven hypotheses for construct validity and three for responsiveness, concerning associations with erythrocyte sedimentation rate, physical function, quality of life, clinical disease states, ultrasound, and treatment response, were formulated. Articles usable to assess - COSMIN based - structural validity, internal consistency, reliability, measurement error, or hypotheses on construct validity or responsiveness were selected and assessed based on COSMIN criteria. Results From the 26 articles using the PMR-AS we were able to use 12 articles. Structural validity, internal consistency, construct validity, and responsiveness were assessed in one, two, eight, and three articles respectively. Insufficient evidence was found to confirm structural validity and internal consistency. No data was found on reliability or measurement error. Although 60% and 67% of hypotheses tested for construct validity and responsiveness were confirmed respectively, there was insufficient evidence to meet criteria for good measurement properties. Conclusion Whilst there is some promising evidence for construct validity and responsiveness of the PMR-AS, it is lacking for other properties and overall falls short of criteria for good measurement properties. Therefore, further research is needed to assess its role in clinical research and care.
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Monitoring and long-term management of giant cell arteritis and polymyalgia rheumatica. Nat Rev Rheumatol 2020; 16:481-495. [DOI: 10.1038/s41584-020-0458-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 02/08/2023]
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Devauchelle-Pensec V, Saraux L, Berthelot JM, De Bandt M, Cornec D, Guellec D, Marhadour T, Jousse-Joulin S, Gouillou M, Saraux A. Assessing polymyalgia rheumatica activity when C-reactive protein is unavailable or uninterpretable. Rheumatology (Oxford) 2018; 57:666-670. [DOI: 10.1093/rheumatology/kex477] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Valérie Devauchelle-Pensec
- Rheumatology Department, CHU Brest, , Brest, France
- INSERM UMR 1227, Laboratoire d’Immunothérapie et Pathologies lymphocytaires B, Labex ‘Immunotherapy, Graft, Oncology’, Université Bretagne occidentale, 29609 Brest Cedex, Brest, France
| | - Lea Saraux
- Rheumatology Department, CHU Brest, , Brest, France
- Institut supérieur de l’électronique et du numérique (ISEN), Brest, France
| | | | - Michel De Bandt
- Rheumatology Department, Fort de France, Martinique, Brest, France
| | - Divi Cornec
- Rheumatology Department, CHU Brest, , Brest, France
- INSERM UMR 1227, Laboratoire d’Immunothérapie et Pathologies lymphocytaires B, Labex ‘Immunotherapy, Graft, Oncology’, Université Bretagne occidentale, 29609 Brest Cedex, Brest, France
| | - Dewi Guellec
- Rheumatology Department, CHU Brest, , Brest, France
| | | | - Sandrine Jousse-Joulin
- Rheumatology Department, CHU Brest, , Brest, France
- INSERM UMR 1227, Laboratoire d’Immunothérapie et Pathologies lymphocytaires B, Labex ‘Immunotherapy, Graft, Oncology’, Université Bretagne occidentale, 29609 Brest Cedex, Brest, France
| | - Maelenn Gouillou
- Clinical Investigation Centre [CIC] 1412, Institut National de la Santé et de la Recherche Médicale [INSERM], Brest, France
| | - Alain Saraux
- Rheumatology Department, CHU Brest, , Brest, France
- INSERM UMR 1227, Laboratoire d’Immunothérapie et Pathologies lymphocytaires B, Labex ‘Immunotherapy, Graft, Oncology’, Université Bretagne occidentale, 29609 Brest Cedex, Brest, France
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Devauchelle-Pensec V. Has the time come for biotherapies in giant cell arteritis and polymyalgia rheumatica? Joint Bone Spine 2016; 83:471-2. [DOI: 10.1016/j.jbspin.2016.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 01/07/2023]
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Muratore F, Pazzola G, Pipitone N, Salvarani C. Recent advances in the diagnosis and treatment of polymyalgia rheumatica. Expert Rev Clin Immunol 2016; 12:1037-45. [DOI: 10.1080/1744666x.2016.1178572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Devauchelle-Pensec V, Berthelot JM, Cornec D, Renaudineau Y, Marhadour T, Jousse-Joulin S, Querellou S, Garrigues F, De Bandt M, Gouillou M, Saraux A. Efficacy of first-line tocilizumab therapy in early polymyalgia rheumatica: a prospective longitudinal study. Ann Rheum Dis 2016; 75:1506-10. [PMID: 26929219 PMCID: PMC4975852 DOI: 10.1136/annrheumdis-2015-208742] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/22/2016] [Indexed: 12/14/2022]
Abstract
Background Glucocorticoids are the cornerstone treatment of polymyalgia rheumatica (PMR) but induce adverse events. Objectives To evaluate the efficacy and safety of first-line tocilizumab in PMR. Methods In a prospective open-label study (ClinicalTrials.gov: NCT01713842), 20 glucocorticoid-free patients fulfilling Chuang's PMR criteria, with symptom onset within the last 12 months and a PMR activity score (PMR-AS) >10, each received three tocilizumab infusions at 4-week intervals, without glucocorticoids, followed by oral prednisone from weeks 12 to 24 (0.15 mg/kg if PMR-AS ≤10 and 0.30 mg/kg otherwise). The primary end point was the proportion of patients with PMR-AS≤10 at week 12. Results Baseline median PMR-AS was 36.6 (IQR 30.4–43.8). At week 12, all patients had PMR-AS≤10 and received the low prednisone dosage. Median PMR-AS at weeks 12 and 24 was 4.5 (3.2–6.8) and 0.95 (IQR 0.4–2), respectively (p<0.001 vs baseline for both time points). No patient required rescue treatment. Positron emission tomography-CT showed significant improvements. The most common adverse events were transient neutropenia (n=3) and leucopenia (n=5); in one patient, the second tocilizumab infusion was omitted due to leucopenia. Conclusions Tocilizumab monotherapy is effective in recent-onset PMR. Randomised controlled trials are warranted. Trial registration number NCT01713842.
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Affiliation(s)
- Valérie Devauchelle-Pensec
- Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France EA 2216, ERI 29, Brest University, Brest, France
| | | | - Divi Cornec
- Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France EA 2216, ERI 29, Brest University, Brest, France
| | | | - Thierry Marhadour
- Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France
| | - Sandrine Jousse-Joulin
- Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France EA 2216, ERI 29, Brest University, Brest, France
| | - Solène Querellou
- Nuclear Medicine Department, Morvan University Hospital, Brest, France
| | - Florent Garrigues
- Radiology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France
| | | | - Maelenn Gouillou
- Clinical Investigation Centre[CIC] 1412, Institut National de la Santé et de la Recherche Médicale[INSERM], Brest, France
| | - Alain Saraux
- Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France EA 2216, ERI 29, Brest University, Brest, France
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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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De Bandt M. Current diagnosis and treatment of polymyalgia rheumatica. Joint Bone Spine 2014; 81:203-8. [DOI: 10.1016/j.jbspin.2013.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 12/01/2022]
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CLEUZIOU CAROLINE, BINARD AYMERIC, DE BANDT MICHEL, BERTHELOT JEANMARIE, SARAUX ALAIN. Contribution of the Polymyalgia Rheumatica Activity Score to Glucocorticoid Dosage Adjustment in Everyday Practice. J Rheumatol 2011; 39:310-3. [DOI: 10.3899/jrheum.110866] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To evaluate the usefulness of the polymyalgia rheumatica (PMR) activity score (PMR-AS) in guiding adjustment of glucocorticoid (GC) dosage.Methods.Rheumatologists prospectively included patients receiving GC therapy for PMR. At each visit, they assessed disease activity using a visual analog scale for physician’s global assessment (VASph) and recorded whether a flare was diagnosed and/or the GC dosage was changed. In each patient, the PMR-AS was calculated using the formula of Leeb and Bird: C-reactive protein (mg/dl) + VAS pain score (0 to 10) + VASph (0 to 10) + (morning stiffness in min × 0.1) + elevation of upper limbs (0–3). We evaluated the correlation between PMR-AS and GC dosage changes in the group already treated with GC.Results.We included 89 patients (mean age 74.6 ± 6.2 yrs; disease duration 1.6 ± 2.2 yrs), who had a total of 149 visits. PMR-AS was available for 137 visits. Of those, 124 involved patients already treated with GC, and 13 patients who started GC treatment. The Spearman correlation coefficient between PMR-AS values and GC dosage change was 0.58 (p < 0.001). In the group already treated with GC, when the PMR-AS was higher than 20, GC dosages were never decreased. When the PMR-AS was between 10 and 20, GC dosages were decreased in 4 patients, unchanged in 4, and increased by < 5 mg in 4 patients. When PMR-AS was < 10, GC dosages were generally decreased.Conclusion.The PMR-AS is helpful for diagnosing flares of PMR and may also assist in everyday practice to decide how to change the GC dosage.
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Björkman MP, Pilvi TK, Kekkonen RA, Korpela R, Tilvis RS. Similar effects of leucine rich and regular dairy products on muscle mass and functions of older polymyalgia rheumatica patients: a randomized crossover trial. J Nutr Health Aging 2011; 15:462-7. [PMID: 21623468 DOI: 10.1007/s12603-010-0276-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Leucine-rich milk and whey proteins have been suggested for prevention of age related loss of muscle mass and strength i.e. sarcopenia. The effects of milk protein supplementation and low intensity home based physical exercise on body composition and muscle functions were investigated. DESIGN A randomized double blind crossover trial. SETTING Community dwelling members of Helsinki rheumatoid association. PARTICIPANTS Older people (N=47, mean age 69.5 years) suffering from polymyalgia rheumatica. INTERVENTION Patients performed as many stand ups as possible twice a day after which they ingested a regular (Control) or a whey protein enriched dairy product with high leucine content (Test). The 8-week intervention periods were separated by a 4-week wash-out. MEASUREMENTS Body composition was measured by dual x-ray absorptiometry and muscle functions by hand grip strength, force platform countermovement jump performance, chair stand test, and walking speed. RESULTS The 16-week home-based post-exercise supplementation resulted in a 1.8% increase (p = 0.052) in lower limb muscle mass. Walking speed (+5.3%, p = 0.007) and chair stand test performance (-12.2 %, p < 0.001) were also improved. Furthermore, a tendency for increased jump power (+3.0%, p = 0.084) was observed. However, significant and consistent differences were not found in the changes of muscle mass indices or muscle functions between supplements, but the test supplement tended to prevent accumulation of body fat. CONCLUSION A low intensity home based exercise program combined with post-exercise milk protein supplementation is feasible despite some gastrointestinal complaints and seems effective in improving the muscle mass and functions of older persons with a inflammatory disease. Further studies are needed to establish, whether and to what extent the use of leucine-enriched whey products prevent or treat age-associated sarcopenia and whether they are superior to the present commercial milk products.
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Affiliation(s)
- M P Björkman
- Clinics of Internal Medicine and Geriatrics, Helsinki University Central Hospital, POB 340, FI-00029 HUS, Helsinki, Finland.
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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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Kreiner F, Galbo H. Effect of etanercept in polymyalgia rheumatica: a randomized controlled trial. Arthritis Res Ther 2010; 12:R176. [PMID: 20854662 PMCID: PMC2991007 DOI: 10.1186/ar3140] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 07/15/2010] [Accepted: 09/20/2010] [Indexed: 11/28/2022] Open
Abstract
Introduction To elucidate in polymyalgia rheumatica (PMR) the role of tumor necrosis factor (TNF) α and the therapeutic potential of blockade with soluble TNF-α receptor, we carried out the first randomized controlled trial with etanercept in PMR. Methods Twenty newly diagnosed, glucocorticoid (GC) naïve patients with PMR and 20 matched non-PMR control subjects completed the trial. Subjects were randomized in a 1:1 ratio to monotherapy with etanercept (25 mg s.c. biweekly) or placebo (saline) for 14 days. Study outcomes were assessed at baseline and after 14 days. The primary outcome was the change in PMR activity score (PMR-AS). Secondary outcomes were: changes in erythrocyte sedimentation rate (ESR) and plasma levels of TNF-α and interleukin (IL) 6; patients' functional status (health assessment questionnaire) and cumulative tramadol intake during the trial. Results At baseline, plasma TNF-α was higher in patients than in controls (P < 0.05). The concentration always increased with etanercept treatment (P < 0.05). In patients, etanercept decreased PMR-AS by 24% (P = 0.011), reflecting significant improvements in shoulder mobility, physician's global assessment and C-reactive protein, and insignificant (P > 0.05) improvements in duration of morning stiffness and patient's assessment of pain. In parallel, ESR and IL-6 were reduced (P < 0.05). Placebo treatment did not change PMR-AS, ESR and IL-6 (P > 0.05). Functional status did not change and tramadol intake did not differ between patient groups. In controls, no changes occurred in both groups. Conclusions Etanercept monotherapy ameliorates disease activity in GC naïve patients with PMR. However, the effect is modest, indicating a minor role of TNF-α in PMR. Trial registration ClinicalTrials.gov (NCT00524381).
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Affiliation(s)
- Frederik Kreiner
- Department of Rheumatology, Institute of Inflammation Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Masson C. Pseudopolyarthrite rhizomélique, maladie de Horton. Critères de diagnostic et de suivi. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.monrhu.2010.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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