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Hofmann W, Kötter I, Winterhalter S, Krupp S. [Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. Z Rheumatol 2024; 83:112-121. [PMID: 38285216 DOI: 10.1007/s00393-024-01484-0] [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] [Indexed: 01/30/2024]
Abstract
Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.
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Affiliation(s)
- W Hofmann
- , An den Uferwiesen 6, 17248, Rechlin/Müritz, Deutschland.
- ehem. Geriatrisches Zentrum, Neumünster und Bad Bramstedt, Deutschland.
| | - I Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- Sektion Rheumatologie und entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - S Winterhalter
- Klinik für Augenheilkunde, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - S Krupp
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Lübeck, Deutschland
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Chatzigeorgiou C, Taylor JC, Elliott F, O’Sullivan EP, Morgan AW, Barrett JH, Mackie SL. Common co-morbidities in polymyalgia rheumatica and giant cell arteritis: cross-sectional study in UK Biobank. Rheumatol Adv Pract 2023; 7:rkad095. [PMID: 38033363 PMCID: PMC10681851 DOI: 10.1093/rap/rkad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/27/2023] [Indexed: 12/02/2023] Open
Abstract
Objective The aim was to determine prevalent co-morbidities in cases with PMR or GCA compared with matched controls. Methods This was a nested, cross-sectional case-control study within the UK Biobank, which recruited participants aged 40-69 years. Case status was defined as self-reported prior diagnosis of PMR or GCA. Ten controls per case were matched for age, sex, ethnicity and assessment centre. Associations with selected self-reported co-morbidities were studied using conditional logistic regression. Results Of PMR (n = 1036) or GCA (n = 102) cases, 72% were female, 98% White, and 58% reported current use of glucocorticoids. Mean age was 63 years. At the time of the assessment visit, compared with controls, PMR/GCA cases were more likely to report poor general health and at least several days of low mood in the past 2 weeks. PMR was associated with hypothyroidism [odds ratio (OR) = 1.34; 95% CI = 1.07, 1.67] and ever-use of HRT (OR = 1.26; 95% CI = 1.07, 1.47). Regarding common co-morbidities, PMR and GCA were both associated with hypertension (PMR: OR = 1.21; 95% CI = 1.06, 1.39; GCA: OR = 1.86; 95% CI = 1.23, 2.81) and cataract (PMR: OR = 1.51; 95% CI = 1.19, 1.93; GCA: OR = 3.84; 95% CI = 2.23, 6.60). Additionally, GCA was associated with depression (OR = 3.05; 95% CI = 1.59, 5.85). Neither condition was associated with diabetes. Conclusion Participants with a history of PMR/GCA, including those not currently taking glucocorticoids, rated their health as poorer than matched controls. Some previously described disease associations (hypothyroidism and early menopause) were replicated. Hypertension and cataract, both of which can be exacerbated by long-term glucocorticoid therapy, were over-represented in both diseases, particularly GCA.
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Affiliation(s)
- Charikleia Chatzigeorgiou
- School of Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John C Taylor
- School of Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
| | - Faye Elliott
- School of Medicine, University of Leeds, Leeds, UK
| | - Eoin P O’Sullivan
- Department of Ophthalmology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ann W Morgan
- School of Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Medicines and In Vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jennifer H Barrett
- School of Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah L Mackie
- School of Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Hofmann W, Kötter I, Winterhalter S, Krupp S. [Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. Z Gerontol Geriatr 2023:10.1007/s00391-023-02211-1. [PMID: 37522895 DOI: 10.1007/s00391-023-02211-1] [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: 03/15/2023] [Accepted: 05/03/2023] [Indexed: 08/01/2023]
Abstract
Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.
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Affiliation(s)
- W Hofmann
- , An den Uferwiesen 6, 17248, Rechlin/Müritz, Deutschland.
- ehem. Geriatrisches Zentrum, Neumünster und Bad Bramstedt, Deutschland.
| | - I Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- Sektion Rheumatologie und entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - S Winterhalter
- Klinik für Augenheilkunde, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - S Krupp
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Lübeck, Deutschland
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Abstract
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease affecting people older than 50 years and is 2-3 times more common in women. The most common symptoms are pain and morning stiffness in the shoulder and pelvic girdle and the onset may be acute or develop over a few days to weeks. General symptoms such as fatigue, fever and weight loss may occur, likely driven by systemic IL-6 signalling. The pathology includes synovial and periarticular inflammation and muscular vasculopathy. A new observation is that PMR may appear as a side effect of cancer treatment with checkpoint inhibitors. The diagnosis of PMR relies mainly on symptoms and signs combined with laboratory markers of inflammation. Imaging modalities including ultrasound, magnetic resonance imaging and positron emission tomography with computed tomography are promising new tools in the investigation of suspected PMR. However, they are still limited by availability, high cost and unclear performance in the diagnostic workup. Glucocorticoid (GC) therapy is effective in PMR, with most patients responding promptly to 15-25 mg prednisolone per day. There are challenges in the management of patients with PMR as relapses do occur and patients with PMR may need to stay on GC for extended periods. This is associated with high rates of GC-related comorbidities, such as diabetes and osteoporosis, and there are limited data on the use of disease-modifying antirheumatic drugs and biologics as GC sparing agents. Finally, PMR is associated with giant cell arteritis that may complicate the disease course and require more intense and prolonged treatment.
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Affiliation(s)
- Ingrid E Lundberg
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ankita Sharma
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Lund-Malmö, Sweden
| | - Aladdin J Mohammad
- Department of Rheumatology, Skåne University Hospital, Lund-Malmö, Sweden.,Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
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Muller S, Hider SL, Sokhal BS, Lawton SA, Helliwell T, Mallen CD. Long-term use of glucocorticoids for polymyalgia rheumatica: follow-up of the PMR Cohort Study. Rheumatol Adv Pract 2022; 6:rkac034. [PMID: 35591903 PMCID: PMC9113421 DOI: 10.1093/rap/rkac034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives PMR is a common inflammatory condition in older adults, characterized by bilateral hip and shoulder pain and stiffness. Reducing oral glucocorticoids, classically used for ≤2 years, are the mainstay of treatment. This study considers the factors early in the disease course that might be associated with prolonged treatment. Methods Six hundred and fifty-two people with incident PMR were recruited from English general practices (2012–2014). Participants completed seven questionnaires over 2 years (used to allocate people to pain–stiffness trajectories) and a further long-term follow-up (LTFU) questionnaire a median of 5.16 years after diagnosis. Characteristics of those still taking and having ceased glucocorticoids were described and compared using Kruskal–Wallis and χ2 and Student’s 2-sample t-tests as appropriate. Results Of the 197 people completing the LTFUQ questionnaire, 179 people reported ever having taken glucocorticoids. Of these, 40.1% were still on treatment, with a median (quartile 1, quartile 3) daily dose of 5 (1.5, 9) mg. People still taking glucocorticoids were more likely to be older (72.5 vs 70.2 years, P = 0.035), live alone (31.8 vs 15.0%, P = 0.01) and have self-managed their glucocorticoid dose (39.1 vs 11.0%, P < 0.0001). They were also more likely to belong to a pain–stiffness trajectory class with sustained symptoms. Conclusions PMR is not always a time-limited condition. Few patient characteristics are associated with prolonged treatment early in the disease course, but those who are older and who have sustained symptoms might be at greater risk. Although accurate prediction is not yet possible, clinicians should monitor people with PMR carefully to manage symptoms and reduce the cumulative glucocorticoid dose.
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Affiliation(s)
- Sara Muller
- Primary Care Centre, Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Samantha L Hider
- Primary Care Centre, Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre,Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | | | - Sarah A Lawton
- Keele Clinical Trials Unit, School of Medicine, Keele University, Keele, UK
| | - Toby Helliwell
- Primary Care Centre, Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Christian D Mallen
- Primary Care Centre, Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre,Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
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Retrospective Analysis of Factors Associated with Fracture in 714 Patients with Polymyalgia Rheumatica. Int J Rheumatol 2022; 2022:9409883. [PMID: 35190743 PMCID: PMC8858072 DOI: 10.1155/2022/9409883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/21/2022] [Accepted: 02/01/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Polymyalgia rheumatica (PMR) is a disease of the elderly, associated with increased fracture risk due to glucocorticosteroid (GC) treatment with the additional possible influence of chronic inflammation. Risk factors for fracture in PMR have not been extensively studied. Hip structure analysis (HSA) is a way to measure bone morphology in the hip using dual X-ray absorptiometry (DEXA). It has been used as a predictor of fracture in epidemiological settings. HSA has not been studied in PMR before. Objectives The object of this retrospective study was to determine if fracture risk in PMR was associated with densitometry data and to determine the influence, if any, of HSA on that association. Methods 714 patients with PMR referred for a bone density estimate at a district general hospital from June 2004 to October 2010 were studied. Demographic data, GC use, alcohol consumption, smoking status, secondary osteoporosis, and fracture history were recorded. Bone mineral density (BMD), Z score, T score, body composition data, and HSA measurements were collected. These were geometric measurements taken from 2-dimensional DEXA images of the hip. Fracture was modelled as an outcome variable using logistic regression models, adjusted for age and sex. And the fit of the model was assessed by comparing the area under the curve (AUC). Results 714 patients were studied, 532 (75%) were female, and mean age was 70.5 with SD of 8.8. 703 (98%) had been treated with GCs. Lumbar and femoral BMD models were significantly associated with fracture. Right femur OR 0.062 (0.014-0.285), left femur OR 0.098 (0.023-0.412), right femoral neck 0.078 (0.014-0.43), left femoral neck 0.104 (0.022-0.492), L1 0.192 (0.066-0.56), L2 OR 0.138 (0.053-0.358), L3 0.192 (0.079-0.463), and L4 0.243 (0.108-0.544). Cross-sectional area was the only HSA parameter that was associated with fracture OR 0.988 (0.980–0.997). Conclusion L2 association models were strongest. Prospective studies are needed to elucidate whether these factors predict future fracture. GC data were binary, not reflecting dose and duration.
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Feasibility and usefulness of a fast-track clinic for patients suspected of polymyalgia rheumatica: notes for a work schedule through a narrative review of published literature. Reumatologia 2021; 59:323-329. [PMID: 34819707 PMCID: PMC8609375 DOI: 10.5114/reum.2021.110600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Fast-track clinics (FTC) have been introduced in different fields and have been reporting significant outcomes in terms of reducing mortality, morbidity, and financial costs. To date, scarce evidence is available for FTC specific for patients suspected of polymyalgia rheumatica (PMR). The primary aim of our paper is to provide an overview of the clinical impact of PMR on patients and the healthcare system by analysing multiple aspects: the median time from onset of symptoms to diagnosis and the burden of the disease both on the healthcare system costs and on patients' quality of life (QoL). Secondarily, based on these data, we aim to discuss the potential advantages and feasibility of a PMR FTC in everyday clinical practice. Material and methods We performed a narrative non-systematic review (PRISMA protocol not followed) of PubMed and Medline (OVID interface) with the following MeSH terms: [polymyalgia rheumatica AND diagnosis OR diagnosis, delayed OR patient care OR early diagnosis OR length of stay OR costs OR healthcare system OR quality of life] or [polymyalgia rheumatica AND glucocorticoids AND side effects]. We decided to exclude every paper that did not report raw data in terms of diagnostic time or delay, hospitalization rate, socio-economic costs on the healthcare system, patients' QoL, and glucocorticoids-related events in PMR patients. Papers focused primarily on giant cell arteritis patients with overlapping PMR were also excluded. Abstract archives of the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) congresses of the last 10 years were screened and included in the search if raw data were available. Each paper's reference list was scanned for additional publications meeting this study's aims. When papers reported data partially presented in previous articles, we opted to use the most recently published data. Results According to our literature review, a PMR FTC might lighten the burden of the disease. Nevertheless, its feasibility depends mostly on the resources of the national health system and of the territorial health district, which are heterogeneously limited. The usefulness of PMR FTCs depends on closer collaboration with the general practitioner because he/she is the first clinician to visit patients with PMR. Conclusions Polymyalgia rheumatica fast-track clinics might lighten the burden of the disease. However, it has some limits that should carefully assessed in planning health policies.
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Aoki D, Kajiwara N, Irishio K, Kato Y, Suezaki S, Kageyama M, Misago M, Tamai D, Nakao S, Ueoka T, Ito M, Murakami S. Withdrawal of Glucocorticoid Therapy is Difficult in Women with Polymyalgia Rheumatica: An Observational Study. Int J Gen Med 2021; 14:6417-6422. [PMID: 34675610 PMCID: PMC8502034 DOI: 10.2147/ijgm.s322111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Objective A total of 105 patients (64 women) who were started on glucocorticoid (GC) treatment for polymyalgia rheumatica (PMR) and/or remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome at Ikeda City Hospital from July 2004 to December 2019 were reviewed (PMR: 81, overlap: 20, pure RS3PE syndrome: 4). Then, 32 cases that had stopped GC and 17 cases that had continued GC for 7.5 years or longer were evaluated (women:men, stopped GC 12:20, continued GC 13:4, respectively) (PMR:overlap:pure RS3PE syndrome, stopped GC 26:6:0, continued GC 14:2:1, respectively). Methods The GC continuation rate in all patients was examined using the Kaplan-Meier method. The following were compared between the two groups: age at starting GC; sex; erythrocyte sedimentation rate, C-reactive protein, hemoglobin, ferritin, aspartate aminotransferase, and alanine aminotransferase before starting GC; days from the onset of symptoms to GC initiation; GC maximum dose; GC dose half a year after its start; presence of relapse; and existence of concomitant malignant disease. Results The GC continuation rate 7.5 years after GC initiation was 52.5%, higher in women (69.2%), than in men (27.1%). The rates then remained unchanged for 15 years. Hemoglobin was high, and relapse was uncommon in the group that stopped GC. There were no differences in other items. Conclusion It is difficult to stop GC therapy for PMR in women in Japan, especially in cases with severe anemia.
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Affiliation(s)
- Dai Aoki
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan.,Fukuchiyama City Hospital Ooe-Branch, Fukuchiyama, Kyoto, Japan
| | - Nobuyuki Kajiwara
- Department of Nephrology, Ikeda City Hospital, Ikeda, Osaka, Japan.,Toyono Town National Health Insurance Clinic, Toyono, Osaka, Japan
| | - Keiko Irishio
- Department of Clinical Research, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Yasuhiro Kato
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shinya Suezaki
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Misaki Kageyama
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Masahiro Misago
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | | | - Shinichiro Nakao
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Takato Ueoka
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Mototoshi Ito
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Shinichiro Murakami
- Department of Emergency and General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan.,Toyono Town National Health Insurance Clinic, Toyono, Osaka, Japan
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Sokhal BS, Hider SL, Paskins Z, Mallen CD, Muller S. Fragility fractures and prescriptions of medications for osteoporosis in patients with polymyalgia rheumatica: results from the PMR Cohort Study. Rheumatol Adv Pract 2021; 5:rkab094. [PMID: 34988356 PMCID: PMC8712242 DOI: 10.1093/rap/rkab094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/18/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
PMR is a common indication for long-term glucocorticoid treatment, leading to an increased risk of osteoporosis and fragility fractures. Guidelines recommend calcium and vitamin D for all patients, in addition to anti-resorptive agents for high-risk patients. The aim of this study was to investigate falls and fragility fracture history and the use of medications for osteoporosis in a PMR cohort.
Methods
Six hundred and fifty-two people with incident PMR responded to a postal survey. Self-reported data on falls, fragility fracture history and medication were collected at baseline. Follow-up data on fragility fractures (hip, wrist and spine) and falls were collected at 12 and 24 months. Logistic regression was used to assess the association between baseline characteristics and fractures.
Results
Fewer than 50% of respondents received osteoporosis treatments, including supplements. One hundred and twelve (17.2%) participants reported a fragility fracture at baseline, 72 participants reported a fracture at 12 months, and 62 reported a fracture at 24 months. Baseline history of falls was most strongly associated with fracture at 12 (odds ratio 2.35; 95% CI: 1.35, 4.12) and 24 months (1.91; 1.05, 3.49) when unadjusted for previous fractures.
Conclusion
Fracture reporting is common in people with PMR. To improve fracture prevention, falls assessment and interventions need to be considered. A history of falls could help to inform prescribing decisions around medications for osteoporosis. Future research should consider both pharmacological and non-pharmacological approaches to reducing fracture risk.
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Affiliation(s)
| | - Samantha L Hider
- School of Medicine, Keele University, Keele
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, Staffordshire, UK
| | - Zoe Paskins
- School of Medicine, Keele University, Keele
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, Staffordshire, UK
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Floris A, Piga M, Chessa E, Congia M, Erre GL, Angioni MM, Mathieu A, Cauli A. Long-term glucocorticoid treatment and high relapse rate remain unresolved issues in the real-life management of polymyalgia rheumatica: a systematic literature review and meta-analysis. Clin Rheumatol 2021; 41:19-31. [PMID: 34415462 PMCID: PMC8724087 DOI: 10.1007/s10067-021-05819-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/19/2021] [Accepted: 06/13/2021] [Indexed: 12/04/2022]
Abstract
A systematic review and meta-analysis were conducted, according to the PRISMA methodology, to summarize current evidence on the prevalence and predictors of long-term glucocorticoid (GC) treatment and disease relapses in the real-life management of polymyalgia rheumatica (PMR). Out of 5442 retrieved studies, 21 were eligible for meta-analysis and 24 for qualitative analysis. The pooled proportions of patients still taking GCs at 1, 2, and 5 years were respectively 77% (95%CI 71–83%), 51% (95%CI 41–61%), and 25% (95CI% 15–36%). No significant difference was recorded by distinguishing study cohorts recruited before and after the issue of the international recommendations in 2010. The pooled proportion of patients experiencing at least one relapse at 1 year from treatment initiation was 43% (95%CI 29–56%). Female gender, acute-phase reactants levels, peripheral arthritis, starting GCs dosage, and tapering speed were the most frequently investigated potential predictors of prolonged GC treatment and relapse, but with inconsistent results. Only a few studies and with conflicting results evaluated the potential role of early treatment with methotrexate in reducing the GC exposure and the risk of relapse in PMR. This study showed that a high rate of prolonged GC treatment is still recorded in the management of PMR. The relapse rate, even remarkable, can only partially explain the long-term GC treatment, suggesting that other and not yet identified factors may be involved. Additional research is needed to profile patients with a higher risk of long-term GC treatment and relapse and identify more effective steroid-sparing strategies.
Key Points: • High rate of long-term glucocorticoid (GC) treatment is recorded in polymyalgia rheumatica (PMR), being 77%, 51%, and 25% of patients still on GCs after respectively 1, 2, and 5 years. • A pooled relapse rate of 43% at 1 year, even remarkable, can only partially explain the long-term GC treatment in PMR. • Several studies have attempted to identify potential predictors of prolonged treatment with GCs and relapse, but with inconsistent results. • Additional research is needed to profile patients with a higher risk of long-term GC treatment and relapse and identify more effective steroid-sparing strategies. |
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Affiliation(s)
- Alberto Floris
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy. .,Dipartimento Di Scienze Mediche E Sanità Pubblica, Università Di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy.
| | - Matteo Piga
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Mattia Congia
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Gian Luca Erre
- Rheumatology Unit, University of Sassari and AOU University Clinic of Sassari, Sassari, Italy
| | - Maria Maddalena Angioni
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Alessandro Mathieu
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
| | - Alberto Cauli
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Cagliari, SS554, 09042, Monserrato, Cagliari, Italy
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Frías-Vargas M, Aguado-Castaño AC, Robledo-Orduña C, García-Lerín A, González-Gay MÁ, García-Vallejo O. [Giant Cell Arteritis. Recommendations in Primary Care]. Semergen 2021; 47:256-266. [PMID: 34112594 DOI: 10.1016/j.semerg.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Giant cell arteritis is a systemic vasculitis with significant intra and extracranial involvement that, with early diagnosis and treatment in primary care, can improve its prognosis as it is a medical emergency. Our working group on vascular diseases of the Spanish Society of Primary Care Physicians (SEMERGEN) proposes a series of recommendations based on current scientific evidence for a multidisciplinary approach and follow-up in primary care.
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Craig G, Knapp K, Salim B, Mohan SV, Michalska M. Treatment Patterns, Disease Burden, and Outcomes in Patients with Giant Cell Arteritis and Polymyalgia Rheumatica: A Real-World, Electronic Health Record-Based Study of Patients in Clinical Practice. Rheumatol Ther 2021; 8:529-539. [PMID: 33638132 PMCID: PMC7991019 DOI: 10.1007/s40744-021-00290-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/10/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Because of the chronic nature of giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR), patients may require continued glucocorticoid treatment to achieve treatment targets or prevent disease relapse, resulting in high cumulative doses. This study evaluated patterns of glucocorticoid use and outcomes in patients with GCA, PMR, or both. METHODS This retrospective study used electronic medical records from a US rheumatology clinic utilizing the JointMan® (Discus Analytics, LLC) rheumatology software. Patients aged ≥ 50 years with a diagnosis of GCA or PMR and ≥ 1 entry for a glucocorticoid prescription after diagnosis were included. Outcomes at 2 years after glucocorticoid initiation included the proportion of patients discontinuing glucocorticoids for ≥ 6 months, proportion of patients discontinuing glucocorticoids for ≥ 6 months and remaining off glucocorticoids at 2 years, time to discontinuation of glucocorticoids for ≥ 6 months, and prednisone dose and were compared between patients with GCA only, PMR only, or GCA and PMR. RESULTS At 2 years after the initiation of glucocorticoids, 32% of patients (26/91) with GCA, 32% (248/779) with PMR, and 27% (26/97) with GCA and PMR discontinued glucocorticoids for ≥ 6 months; 17, 23, and 18% discontinued glucocorticoids for ≥ 6 months and remained off glucocorticoids at 2 years, respectively. Median (range) time to discontinuation of glucocorticoids for ≥ 6 months was 202.5 (0-635) days and shorter in patients with both GCA and PMR vs. GCA or PMR only. The majority of patients required daily prednisone at 2 years, with similar doses observed between groups. CONCLUSIONS Fewer than one-third of patients with GCA and/or PMR discontinued glucocorticoids for ≥ 6 months; the majority of patients required prednisone therapy for ≥ 2 years after its initiation. These data highlight the need for the use of more efficacious and glucocorticoid-sparing therapies in patients with GCA and/or PMR.
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Affiliation(s)
- Gary Craig
- Arthritis Northwest, PLLC, Spokane, WA, USA.
- Discus Analytics, LLC, Spokane, WA, USA.
| | | | - Bob Salim
- Axio Research, LLC, Seattle, WA, USA
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Depression and depressive symptoms in patients with polymyalgia rheumatica: discussion points, grey areas and unmet needs emerging from a systematic review of published literature. Reumatologia 2021; 58:381-389. [PMID: 33456081 PMCID: PMC7792545 DOI: 10.5114/reum.2020.102003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/30/2020] [Indexed: 01/11/2023] Open
Abstract
Objectives In 1979, Bird et al. proposed depression as a diagnostic criterion for polymyalgia rheumatica (PMR). More recently, the significance of depression in PMR patients has been re-proposed, , and some researchers have suggested that PMR may increase the risk of depression. The aim of our article is to evaluate the relationship between PMR and depression. Material and methods Systematic literature searches were performed on 19th and 20th May 2020 based on Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The search was restricted to all studies and case reports with English abstract, published in any language, since 1979 (when depression was first proposed as a diagnostic criterion for PMR) describing the association of PMR with depression. Exclusion criteria were as follows: reviews, conference abstracts, comments, non-original articles; and articles discussing giant cell arteritis (GCA) and PMR when data and observations for the two conditions were not clearly subdivided. Results The initial search yielded 812 papers, of which 115 duplicates were removed. A total of 697 articles had a first screening and 506 were excluded based on title and abstract reviews; 117 articles underwent full-length scrutiny, and 99 full-text articles were excluded because they did not meet the inclusion and exclusion criteria (reviews and comments = 58; articles with outcome of interest not reported = 34; low-quality articles = 7). At least, 18 articles were included in this review. Conclusions The review did not find any studies that clarified the prevalence rates of depression in patients with PMR. Furthermore, the studies reviewed did not offer any clarity as to whether patients suffered from just depressive symptoms or clinical depression, and that accepted diagnostic criteria for depression had not been employed, indicating that a robust method for diagnosing depression had not been employed. Collaboration of different professionals should be improved through shared guidelines.
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Palmowski A, Buttgereit F. Reducing the Toxicity of Long-Term Glucocorticoid Treatment in Large Vessel Vasculitis. Curr Rheumatol Rep 2020; 22:85. [PMID: 33047263 PMCID: PMC7550368 DOI: 10.1007/s11926-020-00961-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
Purpose While glucocorticoids (GCs) are effective in large vessel vasculitis (LVV), they may cause serious adverse events (AEs), especially if taken for longer durations and at higher doses. Unfortunately, patients suffering from LVV often need long-term treatment with GCs; therefore, toxicity needs to be expected and countered. Recent Findings GCs remain the mainstay of therapy for both giant cell arteritis and Takayasu arteritis. In order to minimize their toxicity, the following strategies should be considered: GC tapering, administration of conventional synthetic (e.g., methotrexate) or biologic (e.g., tocilizumab) GC-sparing agents, as well as monitoring, prophylaxis, and treatment of GC-related AEs. Several drugs are currently under investigation to expand the armamentarium for the treatment of LVV. Summary GC treatment in LVV is effective but associated with toxicity. Strategies to minimize this toxicity should be applied when treating patients suffering from LVV.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany.
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Hattori K, Hirano Y, Kojima T. Predictors of glucocorticoid‐free remission in patients with polymyalgia rheumatica treated with prednisolone. Int J Rheum Dis 2020; 23:1581-1586. [DOI: 10.1111/1756-185x.13978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kyosuke Hattori
- Orthopedic Surgery Nagoya University Graduate School of Medicine Nagoya Japan
| | - Yuji Hirano
- Rheumatology Toyohashi Municipal Hospital Toyohashi Japan
| | - Toshihisa Kojima
- Orthopedic Surgery Nagoya University Graduate School of Medicine Nagoya Japan
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Ruediger C, Nguyen L, Black R, Proudman S, Hill C. Efficacy of methotrexate in polymyalgia rheumatica in routine rheumatology clinical care. Intern Med J 2020; 50:1067-1072. [DOI: 10.1111/imj.14779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Carlee Ruediger
- Rheumatology Unit The Queen Elizabeth Hospital Adelaide South Australia Australia
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
| | - Leanne Nguyen
- Rheumatology Unit Royal Adelaide Hospital Adelaide South Australia Australia
| | - Rachel Black
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
- Rheumatology Unit Royal Adelaide Hospital Adelaide South Australia Australia
| | - Susanna Proudman
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
- Rheumatology Unit Royal Adelaide Hospital Adelaide South Australia Australia
| | - Catherine Hill
- Rheumatology Unit The Queen Elizabeth Hospital Adelaide South Australia Australia
- Discipline of Medicine University of Adelaide Adelaide South Australia Australia
- Rheumatology Unit Royal Adelaide Hospital Adelaide South Australia Australia
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Affiliation(s)
- Frank Buttgereit
- Charité University Medicine, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - Eric L Matteson
- Mayo Clinic College of Medicine and Science, Division of Rheumatology, Rochester, Minnesota
| | - Christian Dejaco
- Medical University Graz, Department of Rheumatology and Immunology, Graz, Austria
- Hospital of Brunico (SABES-ASDAA), Department of Rheumatology, Brunico, Italy
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18
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Wang S, Panush RS. Certain perspectives about the use of corticosteroids for managing hospitalized patients with rheumatic diseases. Clin Rheumatol 2020; 39:3131-3136. [DOI: 10.1007/s10067-020-05349-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 11/24/2022]
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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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Muller S, Whittle R, Hider SL, Belcher J, Helliwell T, Morton C, Hughes E, Lawton SA, Mallen CD. Longitudinal clusters of pain and stiffness in polymyalgia rheumatica: 2-year results from the PMR Cohort Study. Rheumatology (Oxford) 2020; 59:1906-1915. [PMID: 31742642 PMCID: PMC7382596 DOI: 10.1093/rheumatology/kez533] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/06/2019] [Indexed: 12/04/2022] Open
Abstract
Objectives To investigate potential subgroups of primary care–diagnosed patients with PMR based on self-reported pain and stiffness severity over time. Methods A total of 652 people with an incident PMR diagnosis were recruited from English general practices and completed a baseline postal questionnaire. They were followed up with a further six questionnaires over a 2 year period. A total of 446 people completed the 2 year follow-up. Pain and stiffness were reported on a 0–10 numerical rating scale. Latent class growth analysis was used to estimate the joint trajectories of pain and stiffness over time. A combination of statistical and clinical considerations was used to choose the number of clusters. Characteristics of the classes were described. Results Five clusters were identified. One cluster represented the profile of ‘classical’ PMR symptoms and one represented sustained symptoms that may not be PMR. The other three clusters displayed a partial recovery, a recovery followed by worsening and a slow, but sustained recovery. Those displaying classical PMR symptoms were in better overall health at diagnosis than the other groups. Conclusion PMR is a heterogeneous condition, with a number of phenotypes. The spectrum of presentation, as well as varying responses to treatment, may be related to underlying health status at diagnosis. Future research should seek to stratify patients at diagnosis to identify those likely to have a poor recovery and in need of an alternative treatment pathway. Clinicians should be aware of the different experiences of patients and monitor symptoms closely, even where there is initial improvement.
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Affiliation(s)
- Sara Muller
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Rebecca Whittle
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Midlands Partnership Foundation Trust, Stoke-on-Trent, UK
| | - John Belcher
- Education Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Toby Helliwell
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Chris Morton
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Emily Hughes
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Sarah A Lawton
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, UK
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Aoki A, Kobayashi H, Yamaguchi Y. Predictors of long-term therapy with glucocorticoid in polymyalgia rheumatica. Mod Rheumatol 2020; 31:417-420. [PMID: 32496843 DOI: 10.1080/14397595.2020.1777680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To investigate the response of glucocorticoid (GC) therapy for patients with polymyalgia rheumatica (PMR) and predictive factors which correspond to the long-term GC. METHODS We reviewed 93 patients with PMR who were treated with GC for more than 6 months. We compared the clinical findings between patients who achieved remission within 24 months (early-remission group, n = 40) and those who required GC therapy for more than 24 months (long-therapy group, n = 24). RESULTS Among 93 patients, 49 have achieved a remission, 35 were undergoing treatment, and 9 have transferred to other hospitals or died. Rate of remission of patients treated for one year GC therapy was in 12% and 53% after 2 years. Serum CRP of long-therapy group was significantly higher than those of the early-remission group. The ratio of patients who experienced more than one relapse within 6 months was 37.5% of long-therapy group and 7.5% of early-remission group. Multivariate logistic regression analysis showed that the history of relapse until 6 months was a significant predictor of long therapy. CONCLUSIONS Some patients need the long-term therapy for more than 4 years. The history of relapse till 6 months is a significant predictor of the long-term GC therapy.
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Affiliation(s)
- Akiko Aoki
- Department of Rheumatology, Department of General Medicine & Primary Care, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Rheumatology, Department of General Medicine & Primary Care, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Yoshiko Yamaguchi
- Department of Rheumatology, Department of General Medicine & Primary Care, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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Comorbidities in patients with polymyalgia rheumatica prior to and following diagnosis: A case control and cohort study. Semin Arthritis Rheum 2020; 50:663-672. [PMID: 32512261 DOI: 10.1016/j.semarthrit.2020.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To determine the burden of comorbidities, including glucocorticoid (GC) related adverse effects, in patients with polymyalgia rheumatica (PMR) before and after diagnosis. METHODS We extracted anonymised electronic medical records of patients over the age of 40 years from the Clinical Practice Research Datalink from 1990-2016. Patients with PMR were individually matched on age, sex and registered General Practice to between three and five controls. The prevalence, cumulative probability and likelihood of a range of comorbidities was estimated. Odds ratios (ORs) and hazard ratios (HRs) were calculated using conditional logistic regression and Cox proportional hazards regression respectively, adjusted for a wide range of covariates. RESULTS 31,984 patients with PMR were matched to 149,436 controls. PMR was prospectively associated with vascular disease (adjusted HR 1.23 [95% confidence interval (CI) 1.19, 1.28]), as well as respiratory (HR 1.25 [1.18, 1.32]), renal (HR 1.34 [1.30, 1.39]), and autoimmune diseases (HR 4.68 [4.35, 5.03]). Conversely, before PMR diagnosis, the risk of cancer (adjusted OR [OR] 0.89 [0.86, 0.93]) and neurological disease (OR 0.36 [0.33, 0.40]) was significantly lower. Patients with PMR had an increased risk of comorbidities associated with glucocorticoid (GC) use. CONCLUSIONS Patients with PMR have a high comorbidity burden, both before and after diagnosis. Whilst further work is needed to more fully understand these associations, clinicians should be aware of the high prevalence of comorbid conditions in this group and the impact that treatment with glucocorticoids may have on comorbidity.
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Views on glucocorticoid therapy in rheumatology: the age of convergence. Nat Rev Rheumatol 2020; 16:239-246. [PMID: 32076129 DOI: 10.1038/s41584-020-0370-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
After decades of sometimes fierce debate about the advantages and disadvantages of glucocorticoids, an age of convergence has been reached. Current recommendations for the management of diseases such as rheumatoid arthritis (RA), polymyalgia rheumatica and large vessel vasculitis reflect the current consensus that as much glucocorticoid as necessary, but as little as possible, should be used. Over the past few years, a range of glucocorticoid-sparing strategies have been developed, as have tools to improve the management of this therapy. A comprehensive view of glucocorticoid-induced osteoporosis has also emerged that recognizes that bone fragility is not solely determined by the dose and duration of glucocorticoid treatment. Nevertheless, open questions remain around whether long-term use of very low doses of glucocorticoids is a realistic option for patients with RA and whether the search for innovative glucocorticoids or glucocorticoid receptor ligands with improved benefit-to-risk ratios will ultimately be successful.
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Shoulder ultrasound and serum lactate dehydrogenase predict inadequate response to glucocorticoid treatment in patients with polymyalgia rheumatica. Rheumatol Int 2020; 40:1101-1109. [PMID: 32062696 DOI: 10.1007/s00296-020-04512-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/04/2020] [Indexed: 10/25/2022]
Abstract
We aimed to identify predictors of inadequate response to glucocorticoid (GC) treatment in patients with polymyalgia rheumatica (PMR). We retrospectively studied 32 patients as a derivation cohort and 24 patients as a validation cohort. The patients were divided into two groups according to the response to GC treatment: GC-responders and GC-inadequate responders (GC-IRs). We compared laboratory data and bilateral shoulder ultrasound findings between the groups. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff value of candidate predictors of treatment response; the predictors were examined using multivariate logistic analysis. Gray-scale ultrasound findings of long head of the biceps (LHB) tenosynovitis and subacromial/subdeltoid (SAD) bursitis were scored semiquantitatively (0-3). A total gray-scale score (TGSS) was calculated as the sum of the gray-scale scores. In the derivation cohort, serum lactate dehydrogenase (LDH) levels and TGSS were significantly higher in GC-IRs than in GC-responders. On ROC analysis, the cutoff values of serum LDH levels ≥ 175 IU/ml and TGSS ≥ 5 were found to be the candidate predictors. Multivariate logistic analysis revealed an independent association of both the predictors with inadequate response to GC treatment. In the validation cohort, patients with one or both predictors exhibited a higher incidence of inadequate response to GC treatment. These findings indicate that the severities of LHB tenosynovitis and SAD bursitis evaluated using ultrasound and serum LDH levels are independent predictors of inadequate response to GC treatment in patients with PMR. Treatment adjustment based on prediction model may allow precise treatment of patients with PMR.
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Camellino D, Giusti A, Girasole G, Bianchi G, Dejaco C. Pathogenesis, Diagnosis and Management of Polymyalgia Rheumatica. Drugs Aging 2020; 36:1015-1026. [PMID: 31493201 DOI: 10.1007/s40266-019-00705-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Polymyalgia rheumatica is an inflammatory rheumatic disease of the elderly characterised by pain and stiffness in the neck and pelvic girdle, and is the second most common inflammatory rheumatic condition in this age group, after rheumatoid arthritis. Polymyalgia rheumatica can occur independently or in association with giant cell arteritis, which is the most common form of primary vasculitis. The diagnosis of polymyalgia rheumatica is usually based on clinical presentation and increase of inflammatory markers. There are no pathognomonic findings that can confirm the diagnosis. However, different imaging techniques, especially ultrasonography, can assist in the identification of polymyalgia rheumatica. Glucocorticoids are the cornerstone of the treatment of polymyalgia rheumatica, but they might be associated with different adverse events. A subgroup of patients presents with a refractory disease course and, in these cases, adding methotrexate as a steroid-sparing agent could be useful. In this review, we summarise the latest findings regarding the pathogenesis, diagnosis and management of polymyalgia rheumatica and try to highlight the possible pitfalls, especially in elderly patients.
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Affiliation(s)
- Dario Camellino
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy.
- Autoimmunology Laboratory, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Andrea Giusti
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Giuseppe Girasole
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, La Colletta Hospital, Azienda Sanitaria Locale 3, Via del Giappone 3, 16011, Arenzano, GE, Italy
| | - Christian Dejaco
- Dienst für Rheumatologie, Servizio di reumatologia, Südtiroler Sanitätsbetrieb, Azienda Sanitaria dell'Alto Adige, Krankenhaus Bruneck, Ospedale di Brunico, Bruneck, Italy
- Department of Rheumatology, Medical University Graz, Graz, Austria
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Treat to Target: A Valid Concept for Management of Polymyalgia Rheumatica and Giant Cell Arteritis? Rheum Dis Clin North Am 2019; 45:549-567. [PMID: 31564296 DOI: 10.1016/j.rdc.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common inflammatory diseases of the elderly. They have variable clinical courses and are usually treated with glucocorticoids (GCs). Relapses are frequent in both conditions. Physicians should balance the tradeoff of treatment-related adverse events and risk of relapse. The ultimate goal of treatment is control of the disease while maintaining patient well-being. A treat-to-target approach may achieve the aim of controlling inflammation and preserving patient's functioning and quality of life, and would require pursuit and evaluation of clinical, laboratory, imaging, and structural targets to tackle the different manifestations of GCA and PMR.
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Leung JL, Owen CE, Buchanan RRC, Liew DFL. Management of polymyalgia rheumatica in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jessica L. Leung
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Claire E. Owen
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Russell R. C. Buchanan
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - David F. L. Liew
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
- Department of Clinical Pharmacology and Therapeutics Austin Health Melbourne Australia
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Dubost JJ, Pereira B, Fan A, Soubrier M. What is the starting dose of steroid prescribed by rheumatologist in the management of polymyalgia rheumatica? Ann Rheum Dis 2019; 80:e133. [PMID: 31455658 DOI: 10.1136/annrheumdis-2019-216050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 11/03/2022]
Affiliation(s)
| | - Bruno Pereira
- Biostatistics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Angelique Fan
- Rheumatology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Martin Soubrier
- Rheumatology, CHU Clermont-Ferrand, Clermont-Ferrand, France
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Management of difficult polymyalgia rheumatica and giant cell arteritis: Updates for clinical practice. Best Pract Res Clin Rheumatol 2019; 32:803-812. [PMID: 31427056 DOI: 10.1016/j.berh.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) represent a family of systemic inflammatory diseases occurring in adults aged 50 years and above. Clinical presentation of PMR/GCA can be variable, making diagnosis at times challenging. There has been an increased appreciation of the role of various large-vessel imaging modalities to help confirm a diagnosis of GCA. Systemic corticosteroids (CS) remain the mainstay of treatment for both PMR and GCA, yet both relapses and CS-related side effects are common. Recent research has demonstrated efficacy of certain biologic agents in these diseases, with particular emphasis on the role of interleukin-6 (IL-6) blockade in GCA. This chapter discusses the latest updates on the diagnosis and treatment of PMR/GCA, with an emphasis on clinical care.
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Jung JY, Lee E, Suh CH, Kim HA. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are associated with disease activity in polymyalgia rheumatica. J Clin Lab Anal 2019; 33:e23000. [PMID: 31402523 PMCID: PMC6868401 DOI: 10.1002/jcla.23000] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/02/2019] [Accepted: 07/17/2019] [Indexed: 12/16/2022] Open
Abstract
Background The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and monocyte‐to‐lymphocyte ratio (MLR) are indicators of systemic inflammation and are useful as markers in systemic rheumatic diseases. In this study, we compared the NLR, PLR, and MLR among patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA), and explored possible associations with clinical features, disease activity, and prognosis in patients with PMR. Methods The study enrolled 94 patients with PMR and 242 patients with RA who were initially diagnosed at the rheumatology clinic of a university‐based tertiary hospital. Symptoms, physical examination, and medical histories were collected with the results of laboratory tests. Results Neutrophil‐to‐lymphocyte ratio (4.5 ± 3.3 vs 2.8 ± 1.8), PLR (222.7 ± 115.5 vs 159.7 ± 78.1), and MLR (0.4 ± 0.3 vs 0.3 ± 0.2) were higher in patients with PMR compared with patients with RA (all P < .001). NLR, PLR, and MLR were correlated with specific laboratory values, including CRP and albumin, in patients with PMR. After disease activity resolved, NLR (2.95 ± 2.32, P < .001), PLR (137.5 ± 82.3, P < .001), and MLR (0.26 ± 0.16, P < .001) decreased significantly. By comparing patients according to the disease course, swollen joint counts were higher in the chronic course group compared with the remission group (P = .03), while the NLR, PLR, and MLR were similar. Conclusions Neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, and monocyte‐to‐lymphocyte ratio levels were associated with disease activity and specific clinical features, although they could not predict prognosis in patients with PMR.
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Eunyoung Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea.,Office of Biostatistics, Ajou Research Institute for Innovative Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Hayashi K, Ohashi K, Watanabe H, Sada KE, Shidahara K, Asano Y, Asano SH, Yamamura Y, Miyawaki Y, Morishita M, Matsumoto Y, Kawabata T, Wada J. Thrombocytosis as a prognostic factor in polymyalgia rheumatica: characteristics determined from cluster analysis. Ther Adv Musculoskelet Dis 2019; 11:1759720X19864822. [PMID: 31367238 PMCID: PMC6643174 DOI: 10.1177/1759720x19864822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 06/28/2019] [Indexed: 11/22/2022] Open
Abstract
Background: This study aimed to identify the clinical subgroups of polymyalgia rheumatica
(PMR) using cluster analysis and compare the outcomes among the identified
subgroups. Methods: We enrolled patients with PMR who were diagnosed at Okayama University
Hospital, Japan between 2006 and 2017, met the 2012 European League Against
Rheumatism/American College of Rheumatology provisional classification
criteria for PMR, and were treated with glucocorticoids. Hierarchical
cluster analysis using variables selected by principal component analysis
was performed to identify the clusters. Subsequently, the outcomes among the
identified clusters were compared in the study. The primary outcome was
treatment response at 1 month after commencement of treatment. The secondary
outcome was refractory clinical course, which was defined as the requirement
of additional treatments or relapse during a 2-year observational
period. Results: A total of 61 consecutive patients with PMR were enrolled in the study. Their
mean age was 71 years, and 67% were female. Hierarchical cluster analysis
revealed three distinct subgroups: cluster 1 (n = 14) was
characterized by patients with thrombocytosis (all patients showed a
platelet count of >45 × 10⁴/µl), cluster 2 (n = 38), by
patients without peripheral arthritis, and cluster 3
(n = 9), by patients with peripheral arthritis. The
patients in cluster 1 achieved treatment response less frequently than those
in cluster 2 (14% versus 47%, p = 0.030).
Refractory cases were more frequent in cluster 1 than in cluster 2; however,
no significant difference was noted (71% versus 42%,
p = 0.06). Conclusions: Thrombocytosis could predict the clinical course in patients with PMR.
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Affiliation(s)
- Keigo Hayashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Keiji Ohashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Haruki Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kitaku, Okayama City 700-8558, Japan
| | - Kenta Shidahara
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yosuke Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Sumie Hiramatsu Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yuriko Yamamura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Michiko Morishita
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yoshinori Matsumoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Tomoko Kawabata
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
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Partington R, Helliwell T, Muller S, Abdul Sultan A, Mallen C. Comorbidities in polymyalgia rheumatica: a systematic review. Arthritis Res Ther 2018; 20:258. [PMID: 30458857 PMCID: PMC6247740 DOI: 10.1186/s13075-018-1757-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/31/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND AIM Comorbidities are known to exist in many rheumatological conditions. Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition affecting older people which, prior to effective treatment, causes severe disability. Our understanding of associated comorbidities in PMR is based only on case reports or series and small cohort studies. The objective of this study is to review systematically the existing literature on the comorbidities associated with PMR. METHODS MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched for original observational research from inception to November 2016. Papers containing the words 'Polymyalgia Rheumatica' OR 'Giant Cell Arteritis' OR the terms 'PMR' OR 'GCA' were included. Article titles were reviewed based on pre-defined criteria by two reviewers. Following selection for inclusion, studies were quality assessed using the Newcastle-Ottawa tool and data were extracted. RESULTS A total of 17,329 papers were reviewed and 41 were incorporated in this review, including three published after the search took place. Wide variations were found in study design, comorbidities reported and populations studied. Positive associations were found between PMR diagnosis and stroke, cardiovascular disease, peripheral arterial disease, diverticular disease and hypothyroidism. Two studies reported a positive association between PMR and overall malignancy rate. Seven studies reported an association between PMR and specific types of cancer, such as leukaemia, lymphoma, myeloproliferative disease and specified solid tumours, although nine studies found either no or negative association between cancer and PMR. CONCLUSION Quantification of the prevalence of comorbidities in PMR is important to accurately plan service provision and enable identification of cases of PMR which may be more difficult to treat. This review highlights that research into comorbidities in PMR is, overall, methodologically inadequate and does not comprehensively cover all comorbidities. Future studies should consider a range of comorbidities in patients with a validated diagnosis of PMR in representative populations.
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Affiliation(s)
- Richard Partington
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, ST5 5BG UK
| | - Toby Helliwell
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, ST5 5BG UK
| | - Sara Muller
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, ST5 5BG UK
| | - Alyshah Abdul Sultan
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, ST5 5BG UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, ST5 5BG UK
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Giollo A, Rossini M, Bettili F, Ghellere F, Fracassi E, Idolazzi L, Gatti D, Viapiana O. Permanent Discontinuation of Glucocorticoids in Polymyalgia Rheumatica Is Uncommon but May Be Enhanced by Amino Bisphosphonates. J Rheumatol 2018; 46:318-322. [PMID: 30385701 DOI: 10.3899/jrheum.180324] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The duration of treatment with glucocorticoids (GC) in polymyalgia rheumatica (PMR) is often longterm. Amino bisphosphonates (N-BP) are used in PMR for the prevention of GC-induced osteoporosis, but they coulsd also have immunomodulatory properties. Whether they can be effective as an adjuvant treatment in PMR is unknown. We aimed to establish whether the use of N-BP in our PMR cohort may be associated with GC discontinuation. METHODS We conducted a retrospective review of all patients diagnosed with PMR recorded in our electronic medical notes. Cox regression analyses were used to examine the association between the use of N-BP and discontinuation of GC. RESULTS Data were retrieved for 385 patients (mean age 71 ± 10 yrs, 64% females, mean initial prednisone dose 19 ± 9 mg/day). The median followup time was 38 months (range 9-57); more than 60% of patients were exposed to N-BP. GC were discontinued in 47% of patients after a median time of 20 months (range 14-27), but subsequently restarted in 39%. Overall, 276/385 patients (72%) were actively treated at their last available evaluation (mean prednisone dose 4.9 ± 5.5 mg/day), while 123/205 (60%) were still receiving GC after 24 months of followup. The use of N-BP was associated with the discontinuation of GC (adjusted HR 0.66, 95% CI 0.50-0.88), independent of age, initial GC dose, and osteoporosis. CONCLUSION Unlike current guidelines, longterm treatment with GC is often necessary. These preliminary data suggest that N-BP may be involved in the management of PMR.
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Affiliation(s)
- Alessandro Giollo
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy. .,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona.
| | - Maurizio Rossini
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Francesco Bettili
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Francesco Ghellere
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Elena Fracassi
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Luca Idolazzi
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Davide Gatti
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
| | - Ombretta Viapiana
- From the Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy.,A. Giollo, MD, Rheumatology Unit, Department of Medicine, University of Verona; M. Rossini, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; F. Bettili, MD, Rheumatology Unit, Department of Medicine, University of Verona; F. Ghellere, MD, Rheumatology Unit, Department of Medicine, University of Verona; E. Fracassi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; L. Idolazzi, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; D. Gatti, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona; O. Viapiana, MD, PhD, Rheumatology Unit, Department of Medicine, University of Verona
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Partington RJ, Muller S, Helliwell T, Mallen CD, Abdul Sultan A. Incidence, prevalence and treatment burden of polymyalgia rheumatica in the UK over two decades: a population-based study. Ann Rheum Dis 2018; 77:1750-1756. [DOI: 10.1136/annrheumdis-2018-213883] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/21/2018] [Accepted: 08/28/2018] [Indexed: 12/14/2022]
Abstract
ObjectivePolymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in older people. Contemporary estimates of the incidence and prevalence are lacking, and no previous study has assessed treatment patterns at a population level. This study aims to address this.MethodsWe extracted anonymised electronic medical records of patients over the age of 40 years from the Clinical Practice Research Datalink in the period 1990–2016. The absolute rate of PMR per 100 000 person-years was calculated and stratified by age, gender and calendar year. Incidence rate ratios were calculated using a Poisson regression model. Among persons with PMR, continuous and total duration of treatment with glucocorticoids (GC) were assessed.Results5 364 005 patients were included who contributed 44 million person-years of follow-up. 42 125 people had an incident diagnosis of PMR during the period. The overall incidence rate of PMR was 95.9 per 100 000 (95% CI 94.9 to 96.8). The incidence of PMR was highest in women, older age groups and those living in the South of England. Incidence appears stable over time. The prevalence of PMR in 2015 was 0.85 %. The median (IQR) continuous GC treatment duration was 15.8 (7.9–31.2) months. However, around 25% of patients received more than 4 years in total of GC therapy.ConclusionsThe incidence rates of PMR have stabilised. This is the first population-based study to confirm that a significant number of patients with PMR receive prolonged treatment with GC, which can carry significant risks. The early identification of these patients should be a priority in future research.
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