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Duarte-Salazar C, Vazquez-Meraz JE, Ventura-Ríos L, Hernández-Díaz C, Arellano-Galindo J. Polymyalgia Rheumatica Post-SARS-CoV-2 Infection. Case Reports Immunol 2024; 2024:6662652. [PMID: 38516555 PMCID: PMC10957256 DOI: 10.1155/2024/6662652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/23/2024] Open
Abstract
There is growing evidence that infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to dysregulation of the immune system and, consequently, the development of autoimmune phenomena. Here, we describe the case of a 75-year-old woman with rheumatic manifestations characterized by intense musculoskeletal pain and stiffness in the neck and shoulders, with sudden onset and with the inability to raise her arms. The patient was admitted with severe pain located in the neck and shoulders. Previously, she had oropharyngeal pain, severe fatigue, and fever; a real-time polymerase chain reaction test for COVID-19 was positive. Two weeks later, the patient presented localized musculoskeletal pain in the neck and shoulders. Relevant laboratory results included an erythrocyte sedimentation rate of 46 mm/hr and a negative rheumatoid factor test; ultrasound findings with bilateral subacromial-subdeltoid bursitis were observed. A diagnosis of polymyalgia rheumatica (PMR) was initially made according to the EULAR/ACR provisional classification criteria for PMR; however, due to C-reactive protein negativity, the diagnosis was established based on symptoms. Management was with prednisone at the dose of 25 mg/day for 4 weeks and progressive reduction until prednisone suspension. The patient showed complete recovery at 6 months of follow-up. In this case, COVID-19 was implicated in the development of autoimmune and inflammatory rheumatic manifestations. PMR is a rare rheumatic condition that should be included in the wide range of rheumatologic manifestations expressed post-SARS-CoV-2 infection.
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Affiliation(s)
- Carolina Duarte-Salazar
- Departmento de Reumatología, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Lucio Ventura-Ríos
- Departmento de Reumatología, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Cristina Hernández-Díaz
- Departmento de Reumatología, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - José Arellano-Galindo
- Laboratorio de Virología Clínica y Experimental, Unidad de Investigación en Enfermedades Infecciosas, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
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Dejaco C, Kerschbaumer A, Aletaha D, Bond M, Hysa E, Camellino D, Ehlers L, Abril A, Appenzeller S, Cid MC, Dasgupta B, Duftner C, Grayson PC, Hellmich B, Hočevar A, Kermani TA, Matteson EL, Mollan SP, Neill L, Ponte C, Salvarani C, Sattui SE, Schmidt WA, Seo P, Smolen JS, Thiel J, Toro-Gutiérrez CE, Whitlock M, Buttgereit F. Treat-to-target recommendations in giant cell arteritis and polymyalgia rheumatica. Ann Rheum Dis 2024; 83:48-57. [PMID: 36828585 PMCID: PMC10803996 DOI: 10.1136/ard-2022-223429] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/11/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES To develop treat-to-target (T2T) recommendations in giant cell arteritis (GCA) and polymyalgia rheumatica (PMR). METHODS A systematic literature review was conducted to retrieve data on treatment targets and outcomes in GCA/PMR as well as to identify the evidence for the effectiveness of a T2T-based management approach in these diseases. Based on evidence and expert opinion, the task force (29 participants from 10 countries consisting of physicians, a healthcare professional and a patient) developed recommendations, with consensus obtained through voting. The final level of agreement was provided anonymously. RESULTS Five overarching principles and six-specific recommendations were formulated. Management of GCA and PMR should be based on shared decisions between patient and physician recognising the need for urgent treatment of GCA to avoid ischaemic complications, and it should aim at maximising health-related quality of life in both diseases. The treatment targets are achievement and maintenance of remission, as well as prevention of tissue ischaemia and vascular damage. Comorbidities need to be considered when assessing disease activity and selecting treatment. CONCLUSION These are the first T2T recommendations for GCA and PMR. Treatment targets, as well as strategies to assess, achieve and maintain these targets have been defined. The research agenda highlights the gaps in evidence and the need for future research.
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Affiliation(s)
- Christian Dejaco
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Medical University, Graz, Austria
- Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Andreas Kerschbaumer
- Abteilung für Rheumatologie, Medizinische Universitat Wien Universitatsklinik fur Innere Medizin III, Wien, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medizinische Universität Wien, Wien, Austria
| | - Milena Bond
- Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, University of Genoa, Genova, Italy
| | - Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Italy
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charite Medical Faculty Berlin, Berlin, Germany
| | - Andy Abril
- Rheumatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Simone Appenzeller
- Departamento de Clínica Médica. Facultade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
| | - Peter C Grayson
- National Institutes of Health/NIAMS, Bethesda, Maryland, USA
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatolgie und Immunologie, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - Alojzija Hočevar
- Department of Rheumatology, Universitiy Medical Centre, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tanaz A Kermani
- Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Lorna Neill
- Patient Charity Polymyalgia Rheumatica and Giant Cell Arteritis Scotland, Nethy Bridge, UK
| | - Cristina Ponte
- Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Sebastian Eduardo Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Philip Seo
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Jens Thiel
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Medical University, Graz, Austria
- Clinic for Rheumatology and Clinical Immunology, University Hospital Freiburg, Faculty of Medicine, Freiburg, UK
| | - Carlos Enrique Toro-Gutiérrez
- Reference Center in Osteoporosis, Rheumatology & Dermatology, Pontificia Universidad Javeriana Cali Facultad de Ciencias de la Salud, Cali, Colombia
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
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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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Kara M, Alp G, Koç AM. Diagnostic difficulties in polymyalgia rheumatica cases with normal erythrocyte sedimentation rate and C-reactive protein values. Medicine (Baltimore) 2023; 102:e35385. [PMID: 37773830 PMCID: PMC10545350 DOI: 10.1097/md.0000000000035385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
Polymyalgia Rheumatica (PMR) is an inflammatory disease which does not have specific diagnostic tests or pathological symptoms and is identified based on clinical characteristics. Among acute phase reactants (APR), the erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) are laboratory findings used in diagnosis and follow-up. In this study, it was aimed to determine the incidence of normal ESH and CRP in patients diagnosed with PMR and identify the distinguishing characteristics of these patients. PMR patients who were clinically diagnosed at a single center were reviewed. After the presence of bursitis was demonstrated with ultrasonography in patients with normal ESR and CRP rates, they were accepted to have PMR. Among all 54 patients (63% female), ESR and CRP values were normal in 8 patients (14%), and serum amyloid A (SAA) was determined to be elevated in all these patients. In the comparisons of the groups with normal and high levels of ESR and CRP, it was found that the group with normal ESR and CRP values had a younger age of diagnosis (P = .027), a longer symptom duration (P < .001), and a lower comorbidity rate (P = .010). PMR patients can have normal ESR and CRP values at the time of their diagnosis. While bursitis can be demonstrated with ultrasonography in patients who are clinically evaluated to have PMR, APRs such as SAA other than ESR and CRP can also be used.
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Affiliation(s)
- Mete Kara
- University of Health Sciences Izmir Bozyaka Research and Training Hospital, Rheumatology Department, Izmir, Turkey
| | - Gülay Alp
- Izmir Katip Celebi University Izmir Atatürk Research and Training Hospital, Rheumatology Department, Izmir, Turkey
| | - Ali Murat Koç
- Izmir Katip Celebi University Izmir Atatürk Research and Training Hospital, Department of Radiology, Izmir, Turkey
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Wendling D. Biological therapy in polymyalgia rheumatica. Expert Opin Biol Ther 2023; 23:1255-1263. [PMID: 37994867 DOI: 10.1080/14712598.2023.2287097] [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: 10/18/2023] [Accepted: 11/20/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of the elderly, treated mainly with systemic corticosteroids. The frequency of side effects of steroids is high in this aged population and increased due to comorbidities. The use of biological treatments could be of interest in this condition. AREAS COVERED This review takes into account literature data from the PubMed and clinical trial databases concerning the results of the use of biological treatments in PMR, in terms of efficacy and safety of these treatments. EXPERT OPINION Current data do not allow us to identify any particular efficacy of the various anti-TNF agents used in the treatment of PMR. Anti-interleukin 6 agents (tocilizumab, sarilumab) have shown consistent efficacy results, suggesting a particularly interesting steroid-sparing effect in the population under consideration. The safety profile appears acceptable. Other biologic targeted treatments are currently being evaluated. Anti-interleukin-6 agents may well have a place in the therapeutic strategy for PMR, particularly for patients with steroid-resistant disease or at high risk of complications of corticosteroid therapy.
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Affiliation(s)
- Daniel Wendling
- Rheumatology, CHU (University Teaching Hospital), Besançon, France
- EA4266 EPILAB, Université de Franche-Comté, Besançon, France
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Manzo C, Milchert M, Venditti C, Castagna A, Nune A, Natale M, Brzosko M. Fever Correlation with Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) Concentrations in Patients with Isolated Polymyalgia Rheumatica (PMR): A Retrospective Comparison Study between Hospital and Out-of-Hospital Local Registries. Life (Basel) 2022; 12:life12070985. [PMID: 35888074 PMCID: PMC9317449 DOI: 10.3390/life12070985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Polymyalgia rheumatica (PMR) is the most common systemic inflammatory rheumatic disease affecting the elderly. Giant cell arteritis (GCA) is a granulomatous vasculitis affecting the aorta and its branches associated with PMR in up to 20% of cases. In recent studies based on university hospital registries, fever correlated with the erythrocyte sedimentation rate (ESR) but not with C-reactive protein (CRP) concentrations at the time of diagnosis in patients with isolated PMR. A long delay to a PMR diagnosis was suggested to explain this discrepancy, possibly caused by laboratory alterations (for instance, anemia of chronic disease type) that can influence only ESR. We performed a retrospective comparison study between the university hospital and two out-of-hospital public ambulatory databases, searching for any differences in fever/low-grade fever correlation with ESR and CRP. Methods: We identified all patients with newly diagnosed PMR between 2013 and 2020, only including patients who had a body temperature (BT) measurement at the time of diagnosis and a follow-up of at least two years. We considered BT as normal at <37.2 °C. Routine diagnostic tests for differential diagnostics were performed at the time of diagnosis and during follow-ups, indicating the need for more in-depth investigations if required. The GCA was excluded based on the presence of suggestive signs or symptoms and routine ultrasound examination of temporal, axillary, subclavian, and carotid arteries by experienced ultrasonographers. Patients with malignancies, chronic renal disease, bacterial infections, and body mass index (BMI) > 30 kg/m2 were excluded, as these conditions can increase CRP and/or ESR. Finally, we used the Cumulative Illness Rating Scale (CIRS) for quantifying the burden of comorbidities and excluded patients with a CIRS index > 4 as an additional interfering factor. Results: We evaluated data from 169 (73 from hospital and 96 from territorial registries) patients with newly diagnosed isolated PMR. Among these, 77.7% were female, and 61.5% of patients had normal BT at the time of diagnosis. We divided the 169 patients into two cohorts (hospital and territorial) according to the first diagnostic referral. Age at diagnosis, ESR, CRP, median hemoglobin (HB), and diagnostic delay (days from first manifestations to final diagnosis) were statistically significantly different between the two cohorts. However, when we assessed these data according to BT in the territorial cohort, we found a statistical difference only between ESR and BT (46.39 ± 19.31 vs. 57.50 ± 28.16; p = 0.026). Conclusions: ESR but not CRP correlates with fever/low-grade fever at the time of diagnosis in PMR patients with a short diagnosis delay regardless of HB levels. ESR was the only variable having a statistically significant correlation with BT in a multilevel regression analysis adjusted for cohorts (β = 0.312; p = 0.014).
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Affiliation(s)
- Ciro Manzo
- Rheumatologic Outpatient Ambulatory, Health District No. 59, Azienda Sanitaria Locale Napoli 3 Sud, 80065 Naples, Italy;
- Correspondence:
| | - Marcin Milchert
- Katedra Reumatologii i Chorób Wewnętrznych, Klinika Chorób Wewnętrznych Reumatologii Diabetologii Geriatrii i Immunologii Klinicznej PUM, 71-457 Szczecin, Poland; (M.M.); (M.B.)
| | - Carlo Venditti
- Rheumatologic Outpatient Clinic Health District Campobasso, Via Ugo Petrella 1, 86100 Campobasso, Italy;
| | - Alberto Castagna
- Primary Care Department, Azienda Sanitaria Provinciale Catanzaro, 88068 Soverato, Italy;
| | - Arvind Nune
- Department of Rheumatology, Southport and Ormskirk Hospital NHS Trust, Southport PR8 6PN, UK;
| | - Maria Natale
- Rheumatologic Outpatient Ambulatory, Health District No. 59, Azienda Sanitaria Locale Napoli 3 Sud, 80065 Naples, Italy;
| | - Marek Brzosko
- Katedra Reumatologii i Chorób Wewnętrznych, Klinika Chorób Wewnętrznych Reumatologii Diabetologii Geriatrii i Immunologii Klinicznej PUM, 71-457 Szczecin, Poland; (M.M.); (M.B.)
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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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