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Rahimi M, Esalatmanesh K, Daneshvar S, Irvani SSN, Badali A, Khabbazi A. Outcomes of polymyalgia rheumatica in real-world practice: a longitudinal cohort study. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 62:286-294. [PMID: 38470357 DOI: 10.2478/rjim-2024-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 03/13/2024]
Abstract
Background: Polymyalgia rheumatica (PMR) is an inflammatory condition closely linked with giant cell arteritis, which is a large vessel vasculitis. To provide real-world evidence on PMR outcomes and their determinants, we conducted a longitudinal study focusing on symptom relief and acute phase reactant normalization. Methods: We followed patients with PMR who were registered in Tabriz University of Medical Sciences Vasculitis Registry (TUOMS-VR) until February 2023. We measured sustained remission (primary outcome) and secondary outcomes including glucocorticoids (GCs)-free remission, medication-free remission, relapse rate and disease-induced damage. Results: We identified eighty-one patients with PMR and followed them for a median time of 57 months. In a median duration of 3 weeks, 98.8% of patients achieved symptom control, with 86.4% achieving sustained remission in a median duration of 9 weeks. Sustained remission was more common in non-smokers and adherent to therapy patients. Relapse occurred in 22.1% of patients, primarily due to non-adherence. Medication-free remission was observed in 30.9% of patients, especially among females and those with an initial prednisolone dose > 15 mg/d. Damage occurred in 42.0% of patients. Conclusion: Although sustained remission in PMR is not an unattainable goal in daily practice and most patients are in remission at the last visit, two-thirds of patients require long-term treatment.
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Affiliation(s)
- Mehran Rahimi
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | - Kamal Esalatmanesh
- 2Internal Medicine Group, Kashan University of Medical Sciences, Kashan, Iran
| | - Sara Daneshvar
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | | | - Ahmadreza Badali
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
| | - Alireza Khabbazi
- 1Connective Tissue Diseases Research Center, Tabriz University of Medical Science, Iran
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Hysa E, Casabella A, Gotelli E, Campitiello R, Schenone C, Genova C, Tanda ET, Sulli A, Smith V, Cimmino MA, Paolino S, Cutolo M. Polymyalgia rheumatica and giant cell arteritis induced by immune checkpoint inhibitors: A systematic literature review highlighting differences from the idiopathic forms. Autoimmun Rev 2024; 23:103589. [PMID: 39117006 DOI: 10.1016/j.autrev.2024.103589] [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: 04/18/2024] [Revised: 08/03/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION An altered immune tolerance disturbed by immune checkpoint inhibitors (ICIs) may contribute to new-onset polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). This systematic literature review (SLR) examines the characteristics of PMR and GCA-like syndromes following anticancer treatment with ICIs, summarizing their demographic, clinical and treatment-related features to provide insights whether they differ from the idiopathic forms. METHODS The SLR was conducted in Medline and EMBASE databases from inception to July 2024, and in the EULAR/ACR abstract database (2021-2023). ICI-induced PMR and GCA syndromes were compared to the primary forms of the diseases using data from studies that included both groups as comparators. For manuscripts lacking direct comparisons, we summarized the main findings and discussed the differences using systematic reviews or large observational studies on the primary forms. RESULTS From 1237 screened abstracts, 46 met the inclusion criteria, involving 358 patients (314 with ICI-PMR and 44 with ICI-GCA). ICI-PMR had an estimated pooled prevalence of 0.1% [95% CI: 0.07%, 0.14%] among ICI recipients and 15.9% [95% CI: 12.6%, 19.9%] among patients experiencing rheumatic immune-related adverse events. Patients with ICI-PMR had a male-to-female ratio of 1.7:1 and a mean age of 71 ± 4 years. Most cases were associated with PD1/PDL1 blockers (87%). Clinical features included inflammatory pain in the girdles (100%), though pelvic girdle involvement was under-reported in some cases (3/28 studies). Peripheral arthritis was present in 35% of patients. Laboratory tests showed normal or slightly elevated inflammatory markers in 26% of cases. Glucocorticoids (GCs) led to symptom improvement in 84% of cases although 20% required immunosuppressive treatment and 14% experienced relapses. ICI-GCA had a prevalence of 0.06% among ICI recipients, with equal gender distribution and a mean age of 71 ± 5 years. Most patients received anti-PD1/PDL1 blockers (57%). Clinical manifestations included cephalic symptoms (75%), permanent visual loss (23%) and symptoms related to large-vessel involvement (54%). High-dose GCs were effective, with 96% achieving remission, though 17% experienced relapses. CONCLUSIONS ICI-induced PMR and GCA may have distinct clinical profiles compared to idiopathic forms, with potentially milder symptoms and better treatment responses. Further studies are needed to confirm these findings and better understand the long-term outcomes and pathophysiology of these conditions.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; Department of Experimental Medicine (DIMES), University of Genova, Genoa, Italy
| | | | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Rosanna Campitiello
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Genova
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Academic Oncology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - Enrica Teresa Tanda
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; UOC Medical Oncology Clinic 2, Department of Internal Medicine, University of Genova, Genoa, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Department of Rheumatology, Ghent University Hospital, Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Marco Amedeo Cimmino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Concurrent baseline diagnosis of giant cell arteritis and polymyalgia rheumatica - A systematic review and meta-analysis. Semin Arthritis Rheum 2022; 56:152069. [PMID: 35858507 DOI: 10.1016/j.semarthrit.2022.152069] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) can be concurrent diseases. We aimed to estimate the point-prevalence of concurrent GCA and PMR. Additionally, an incidence rate (IR) of GCA presenting after PMR diagnosis in patients was estimated. METHODS Two authors performed a systematic literature search, data extraction and risk of bias assessment independently. Studies assessing cohorts of patients presenting with both GCA and PMR were included. The outcomes were point-prevalence of concurrent GCA and PMR and IR for development of GCA after PMR diagnosis. A meta-analysis was performed to calculate a pooled prevalence of concurrent PMR and GCA. RESULTS We identified 29 studies investigating concurrent GCA and PMR. Only two studies applied imaging systematically to diagnose GCA and none to diagnose PMR. GCA presenting after PMR diagnosis was assessed in 12 studies but imaging was not applied systematically. The point-prevalence of concurrent GCA present at PMR diagnosis ranged from 6%-66%. The pooled estimate of the point-prevalence from the meta-analysis was 22%. The point-prevalence of PMR present at GCA diagnosis ranged from 16%-65%. The pooled estimate of the point-prevalence from the meta-analysis was 42%. The IR ranged between 2-78 cases of GCA presenting after PMR per 1000 person-years. CONCLUSION This review and meta-analysis support that concurrent GCA and PMR is frequently present at the time of diagnosis. Additionally, we present the current evidence of GCA presenting in patients after PMR diagnosis. These results emphasize the need for studies applying imaging modalities to diagnose GCA.
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Ponce A, Frade-Sosa B, Sarmiento-Monroy JC, Sapena N, Ramírez J, Azuaga AB, Morlà R, Ruiz-Esquide V, Cañete JD, Sanmartí R, Gómez-Puerta JA. Imaging Findings in Patients with Immune Checkpoint Inhibitor-Induced Arthritis. Diagnostics (Basel) 2022; 12:1961. [PMID: 36010310 PMCID: PMC9406920 DOI: 10.3390/diagnostics12081961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 01/27/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced arthritis is an increasingly recognized adverse event in patients with oncologic disease during immunotherapy. Four patterns are well described, including rheumatoid arthritis (RA)-like, polymyalgia rheumatica (PMR)-like, psoriatic arthritis (PsA)-like, and oligo-monoarthritis, among others. Despite better clinical recognition of these syndromes, information about the main imaging findings is limited. METHODS We conducted a retrospective observational study including all adult patients referred to the Rheumatology Department of a single-center due to ICI-induced arthritis who underwent imaging studies [ultrasound (US), magnetic resonance imaging (MRI), and 18F-FDG PET/CT)] between January 2017 and January 2022. RESULTS Nineteen patients with ICI-induced arthritis with at least one diagnostic imaging assessment were identified (15 US, 4 MRI, 2 18F-FDG PET/CT). Most patients were male (84.2%), with a median age at inclusion of 73 years. The main underlying diagnoses for ICI treatment were melanoma in five cases. The distribution of ICI-induced arthritis was as follows: PMR-like (5, 26.2%), RA-like (4, 21.1%), PsA-like (4, 21.1%), and others (6, 31.6%). All RA-like patients had US findings indistinguishable from conventional RA patients. In addition, 3/5 (60%) of PMR-like patients had significant involvement of the hands and wrists. Abnormal findings on MRI or PET-CT were reported by clinical symptoms. No erosions or myofascitis were seen. CONCLUSIONS ICI-induced arthritis patients present inflammatory patterns on imaging studies similar to conventional inflammatory arthropathies, and therefore these syndromes should be followed carefully and treated according to these findings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - José A. Gómez-Puerta
- Department of Rheumatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
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Leão RV, Calich ALG, Calich I, Rodrigues MB, Helito PVP, Amaral DT, Pereira RFB, Correa MFDP. Magnetic resonance imaging findings in patients with polymyalgia rheumatica. Radiol Bras 2022; 55:346-352. [PMID: 36514685 PMCID: PMC9743254 DOI: 10.1590/0100-3984.2021.0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 12/16/2022] Open
Abstract
Objective To describe the prevalence of magnetic resonance imaging (MRI) findings in patients with the clinical diagnosis of polymyalgia rheumatica (PMR). Materials and Methods Sixteen consecutive patients with untreated PMR, meeting the American College of Rheumatology criteria, underwent MRI examinations of the shoulder(s), hip(s), or both, depending on clinical complaints. Six patients also underwent MRI of the spine. Results We evaluated 24 shoulders, among which we identified subacromial-subdeltoid bursitis in 21 (87.5%), glenohumeral joint effusion in 17 (70.8%), and fluid distention of the long head of the biceps tendon sheath in 15 (62.5%). Peritendinitis and capsular edema were observed in 21 (87.5%) and 17 (70.8%) shoulders, respectively. We also evaluated 17 hips, identifying hip joint effusion in 12 (70.6%), trochanteric bursitis in 11 (64.7%), peritendinitis in 17 (100%), and capsular edema in 14 (82.4%). All six of the patients who underwent MRI of the spine were found to have interspinous bursitis. Conclusion Subacromial-subdeltoid bursitis, glenohumeral joint effusion, and hip joint effusion are common findings in patients with PMR. In addition, such patients appear to be highly susceptible to peritendinitis and capsular edema. There is a need for case-control studies to validate our data and to determine the real impact that these findings have on the diagnosis of PMR by MRI.
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Affiliation(s)
- Renata Vidal Leão
- Hospital Sírio-Libanês, São Paulo, SP, Brazil. , Instituto de Radiologia do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil. ,Correspondence: Dra. Renata Vidal Leão. Department of Radiology,
Hospital Sírio-Libanês. Rua Dona Adma Jafet, 91, Bela Vista. São
Paulo, SP, Brazil, 01308-050.
| | | | | | - Marcelo Bordalo Rodrigues
- Hospital Sírio-Libanês, São Paulo, SP, Brazil. , Instituto de Radiologia do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil.
| | - Paulo Victor Partezani Helito
- Hospital Sírio-Libanês, São Paulo, SP, Brazil. , Instituto de Radiologia do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil.
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Toro-Gutiérrez CE, Cañas CA, Mantilla RD, Beltrán S, Pastrana-Gonzalez V, Vecino MJ, Rodriguez-Jimenez M, Rojas M. Polymyalgia rheumatica: A case series from Colombia and analysis of Latin America. J Transl Autoimmun 2021; 4:100115. [PMID: 34485886 PMCID: PMC8391016 DOI: 10.1016/j.jtauto.2021.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Polymyalgia rheumatica (PMR) is the most common inflammatory disease in patients over 50 years. Information about the disease in Latin America (LATAM) is scarce. We aimed to evaluate a group of Colombian patients with PMR and to conduct a systematic review of PMR in LATAM. METHODS A multicentric retrospective study was performed. Medical records of 256 PMR patients were evaluated. Patients were divided into two groups, those fulfilling the 2012 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for PMR and those who did not (i.e., clinical diagnosis). A systematic literature review and meta regression was performed comparing Colombian vs LATAM patients. RESULTS From 256 patients, 145 (56.6%) fulfilled the 2012 EULAR/ACR criteria, and 111 (43.3%) were classified by clinical diagnosis. Inflammatory bilateral shoulder pain, pelvic girdle aching, morning stiffness >45 min, elevated erythrocyte sedimentation rate (ESR), and C-reactive protein (CPR), and Methotrexate (MTX) prescription were more common in the 2012 EULAR/ACR group. None of the included patients presented overt polyautoimmunity (PolyA), whereas up to 24% exhibited latent PolyA. In addition, these patients showed high frequency of malignancy (7.59%). In the meta regression analysis, Colombian patients exhibited lower ESR levels, and were less likely to develop giant cell arteritis (GCA) as compared to the rest of LATAM data. CONCLUSION Patients with PMR in LATAM exhibit similar phenotypes from other cohorts worldwide. Malignancy, GCA and latent PolyA should be considered in the routine clinical follow-up of patients with PMR.
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Key Words
- ACPA, Cyclic citrullinated peptide antibody.
- ANAs, Antinuclear antibodies.
- CART, Classification and regression trees.
- CI, Confidence interval.
- CRP, C-reactive protein.
- DMARDs, Disease-modifying antirheumatic drugs.
- ESR, Erythrocyte sedimentation rate.
- EULAR/ACR, European League Against Rheumatism/American College of Rheumatology.
- GCA, Giant cell arteritis
- GCs, Glucocorticoids.
- Giant cell arteritis
- IQR, Interquartile range.
- LATAM, Latin America.
- Latin America
- MTX, Methotrexate.
- Neoplasms
- OR, Odds ratio.
- PMR, Polymyalgia rheumatica.
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐analyses.
- PolyA, Polyautoimmunity.
- Polyautoimmunity
- Polymyalgia rheumatica
- RF, Rheumatoid factor.
- SD, Standard deviation.
- Systematic review
- ts-DMARDs, Targeted-synthetic disease-modifying antirheumatic drugs.
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Affiliation(s)
| | | | - Rubén D. Mantilla
- Dermatology and Rheumatology Foundation (FUNINDERMA), Bogota, Colombia
| | - Santiago Beltrán
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | | | | | - Mónica Rodriguez-Jimenez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
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Van Hemelen M, Betrains A, Vanderschueren S, Blockmans D. Impact of age at diagnosis in polymyalgia rheumatica: A retrospective cohort study of 218 patients. Autoimmun Rev 2020; 19:102692. [PMID: 33131702 DOI: 10.1016/j.autrev.2020.102692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polymyalgia rheumatica (PMR) is a common musculoskeletal inflammatory disease that may occur with giant-cell arteritis (GCA) or in an isolated form. While the incidence is highest in the elderly, there is a paucity of data on its presentation, clinical course and response to treatment in younger individuals. METHODS We conducted a retrospective review of 40 patients who were diagnosed with isolated PMR under the age of 60 and 178 patients diagnosed above this age, taking into account clinical and laboratory data and treatment history. RESULTS Patients who were diagnosed at a younger age had lower acute-phase reactant levels at diagnosis but not after initiation of treatment or at the time of relapse. The risk of relapse was lower in the group diagnosed under age 60 (35% vs 55%). Cumulative and maximal glucocorticoid doses, use of glucocorticoid-sparing agents and duration of glucocorticoid treatment, did not differ between the groups. In multivariate analysis, younger age at diagnosis was associated with cervical pain and male gender. CONCLUSION Compared to patients diagnosed above age 60, patients diagnosed with PMR at a younger age have a lower risk of relapse, but similar long-term outcomes with regards to continued need for treatment.
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Affiliation(s)
- Maarten Van Hemelen
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disease, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disease, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disease, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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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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Manzo C, Emamifar A. Polymyalgia Rheumatica and Seronegative Elderly-Onset Rheumatoid Arthritis: Two Different Diseases with Many Similarities. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10313508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Polymyalgia rheumatica (PMR) and seronegative elderly-onset rheumatoid arthritis (SEORA) are two of the most frequent inflammatory rheumatologic diseases in elderly patients. At first presentation, there are many similarities between PMR and SEORA, that may lead to a real diagnostic conundrum. The most relevant similarities and differences between PMR and SEORA are discussed in this review. In addition to the acute involvement of the shoulder joints, important features characterising both diseases are morning stiffness longer than 45 minutes, raised erythrocyte sedimentation rate, and a good response to low doses of prednisone. Some findings (such as erosive arthritis or symmetrical involvement of metacarpophalangeal and/or proximal interphalangeal joints) can help to make the diagnosis of SEORA, whereas shoulder and hip ultrasonography and 18-FDG PET/CT seem to be less specific. However, in several patients only long-term follow-ups confirm the initial diagnosis. A definite diagnosis of PMR or SEORA has significant therapeutic implications, since patients with PMR should be treated with long-term glucocorticoids, and sometimes throughout life, which predisposes the patients to serious side effects. On the contrary, in patients with SEORA, short-term treatment with glucocorticoids should be considered when initiating or changing disease modifying antirheumatic drugs, followed by rapid tapering.
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Affiliation(s)
- Ciro Manzo
- Internal and Geriatric Medicine Department, Rheumatologic Outpatient Clinic Hospital “Mariano Lauro”, Sant’Agnello, Italy
| | - Amir Emamifar
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Diagnostic Center, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark
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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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Miceli MC, Zoli A, Peluso G, Bosello S, Gremese E, Ferraccioli G. Baseline Shoulder Ultrasonography Is Not a Predictive Marker of Response to Glucocorticoids in Patients with Polymyalgia Rheumatica: A 12-month Followup Study. J Rheumatol 2016; 44:241-247. [PMID: 27980012 DOI: 10.3899/jrheum.160090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2016] [Indexed: 11/22/2022]
Abstract
Objective.In this study, we evaluated whether ultrasound (US) subdeltoid bursitis (SB) and/or biceps tenosynovitis (BT) presence at baseline could represent a predictive marker of response to standard therapy after 12 months of followup, and whether a positive US examination could highlight the need of higher maintenance dosage of glucocorticoids (GC) at 6 and 12 months in patients with polymyalgia rheumatica (PMR).Methods.Sixty-six consecutive patients with PMR underwent bilateral shoulder US evaluations before starting therapy and after 12 months of followup. Absence of girdle pain and morning stiffness (clinical remission) and laboratory variables were evaluated. After diagnosis, all patients were treated with prednisone.Results.At baseline, SB and/or BT were present in 46 patients (70%), of whom 33 (72%) became negative while 13 (28%) remained positive at the 12-month US evaluation. All patients rapidly achieved a clinical remission, and at 6 months 26 (39%) also achieved a laboratory variable normalization. According to US positivity at baseline, no difference was found in remission or relapse rate after 12 months. Thirty patients (46%) at 6 months and 7 (11%) at 12 months were still taking more than 5 mg/day of prednisone. According to the US pattern at baseline, no difference was found in the mean GC dose at 6 and 12 months.Conclusion.In patients with PMR, the presence of SB and/or BT on US at diagnosis is not a predictive marker of GC response or of a higher GC dosage to maintain remission in a 12-month prospective followup study.
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Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. Rheumatology (Oxford) 2016; 56:506-515. [DOI: 10.1093/rheumatology/kew273] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Indexed: 01/17/2023] Open
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Dejaco C, Singh YP, Perel P, Hutchings A, Camellino D, Mackie S, Abril A, Bachta A, Balint P, Barraclough K, Bianconi L, Buttgereit F, Carsons S, Ching D, Cid M, Cimmino M, Diamantopoulos A, Docken W, Duftner C, Fashanu B, Gilbert K, Hildreth P, Hollywood J, Jayne D, Lima M, Maharaj A, Mallen C, Martinez-Taboada V, Maz M, Merry S, Miller J, Mori S, Neill L, Nordborg E, Nott J, Padbury H, Pease C, Salvarani C, Schirmer M, Schmidt W, Spiera R, Tronnier D, Wagner A, Whitlock M, Matteson EL, Dasgupta B. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol 2016; 67:2569-80. [PMID: 26352874 DOI: 10.1002/art.39333] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 07/13/2015] [Indexed: 12/12/2022]
Abstract
Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients' and clinicians' values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.
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Affiliation(s)
- Christian Dejaco
- Medical University Graz, Department of Rheumatology, Graz, Austria, and Southend University Hospital, Department of Rheumatology, Essex, UK
| | - Yogesh P Singh
- Southend University Hospital, Department of Rheumatology, Essex, UK
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, Epidemiology and Population Health Faculty, London, UK
| | - Andrew Hutchings
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, UK
| | - Dario Camellino
- University of Genoa, Department of Internal Medicine, Research Laboratory and Academic Division of Clinical Rheumatology, Genoa, Italy
| | - Sarah Mackie
- University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Andy Abril
- Mayo Clinic, Department of Rheumatology, Jacksonville, Florida
| | - Artur Bachta
- Military Institute of Medicine, Department of Internal Medicine and Rheumatology, Warsaw, Poland
| | - Peter Balint
- National Institute of Rheumatology and Physiotherapy, 3rd Rheumatology Department, Budapest, Hungary
| | | | | | - Frank Buttgereit
- Charité University Medicine, Department of Rheumatology, Berlin, Germany
| | - Steven Carsons
- Stony Brook University School of Medicine, Division of Rheumatology, Allergy and Immunology, Winthrop-University Hospital Campus, Mineola, New York
| | - Daniel Ching
- Timaru Hospital, Department of Rheumatology, Timaru, New Zealand
| | - Maria Cid
- University of Barcelona Hospital Clinic, Department of Systemic Autoimmune Diseases, Barcelona, Spain
| | - Marco Cimmino
- University of Genoa, Department of Internal Medicine, Research Laboratory and Academic Division of Clinical Rheumatology, Genoa, Italy
| | | | - William Docken
- Brigham and Women's Hospital, Division of Rheumatology, Boston, Massachusetts
| | - Christina Duftner
- Medical University of Innsbruck, Department of Internal Medicine-Clinic VI, Innsbruck, Austria
| | - Billy Fashanu
- Southend University Hospital, Department of Rheumatology, Essex, UK
| | - Kate Gilbert
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Pamela Hildreth
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Jane Hollywood
- Southend University Hospital, Department of Rheumatology, Essex, UK
| | - David Jayne
- University of Cambridge, Department of Medicine, Cambridge, UK
| | - Manuella Lima
- Hospital Universitário Pedro Ernesto, Department of Rheumatology, Rio de Janeiro, Brazil
| | - Ajesh Maharaj
- University of Kwa Zulu Natal, Prince Mshiyeni Memorial Hospital, Nelson R. Mandela School of Medicine, Department of Internal Medicine, Durban, South Africa
| | - Christian Mallen
- Keele University, Arthritis Research UK Primary Care Centre, Keele, UK
| | - Victor Martinez-Taboada
- Universidad de Cantabria, Hospital Universitario Marqués de Valdecilla, Facultad de Medicina, Servicio de Reumatología, Santander, Spain
| | - Mehrdad Maz
- University of Kansas Medical Center, Department of Medicine, Division of Allergy, Clinical Immunology, and Rheumatology, Kansas City
| | - Steven Merry
- Mayo Clinic, Department of Family Medicine, Rochester, Minnesota
| | - Jean Miller
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Shunsuke Mori
- NHO Kumamoto Saishunsou National Hospital, Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, Kohshi, Kumamoto, Japan
| | - Lorna Neill
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Elisabeth Nordborg
- Sahlgren University Hospital, Department of Rheumatology, Göteborg, Sweden
| | - Jennifer Nott
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Hannah Padbury
- patient representatives from Polymyalgia Rheumatica and Giant Cell Arteritis UK, London, UK
| | - Colin Pease
- University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Carlo Salvarani
- Azienda Ospedaliera-IRCCS di Reggio Emilia, Department of Internal Medicine, Division of Rheumatology, Reggio Emilia, Italy
| | - Michael Schirmer
- Medical University of Innsbruck, Department of Internal Medicine-Clinic VI, Innsbruck, Austria
| | - Wolfgang Schmidt
- Immanuel Krankenhaus Berlin and Medical Center for Rheumatology Berlin-Buch, Berlin, Germany
| | - Robert Spiera
- Hospital for Special Surgery, Department of Medicine, New York, New York
| | - David Tronnier
- patient representative from the Mayo Clinic, Rochester, Minnesota
| | - Alexandre Wagner
- Universidade Federal de São Paulo, Department of Internal Medicine, São Paulo, Brazil
| | | | - Eric L Matteson
- Mayo Clinic College of Medicine, Department of Health Sciences Research, Division of Rheumatology, Rochester, Minnesota
| | - Bhaskar Dasgupta
- Southend University Hospital, Department of Rheumatology, Essex, UK
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Dejaco C, Singh YP, Perel P, Hutchings A, Camellino D, Mackie S, Matteson EL, Dasgupta B. Current evidence for therapeutic interventions and prognostic factors in polymyalgia rheumatica: a systematic literature review informing the 2015 European League Against Rheumatism/American College of Rheumatology recommendations for the management of polymyalgia rheumatica. Ann Rheum Dis 2015; 74:1808-17. [DOI: 10.1136/annrheumdis-2015-207578] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dejaco C, Singh YP, Perel P, Hutchings A, Camellino D, Mackie S, Abril A, Bachta A, Balint P, Barraclough K, Bianconi L, Buttgereit F, Carsons S, Ching D, Cid M, Cimmino M, Diamantopoulos A, Docken W, Duftner C, Fashanu B, Gilbert K, Hildreth P, Hollywood J, Jayne D, Lima M, Maharaj A, Mallen C, Martinez-Taboada V, Maz M, Merry S, Miller J, Mori S, Neill L, Nordborg E, Nott J, Padbury H, Pease C, Salvarani C, Schirmer M, Schmidt W, Spiera R, Tronnier D, Wagner A, Whitlock M, Matteson EL, Dasgupta B. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2015; 74:1799-807. [DOI: 10.1136/annrheumdis-2015-207492] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ochi J, Nozaki T, Okada M, Suyama Y, Kishimoto M, Akaike G, Tasaki A, Ohde S, Saida Y, Yoshioka H. MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica. Mod Rheumatol 2015; 25:761-7. [PMID: 25698371 DOI: 10.3109/14397595.2015.1008725] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR). METHODS MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed. RESULTS The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05). CONCLUSIONS Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.
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Affiliation(s)
- Junko Ochi
- a Department of Radiology , St. Luke's International Hospital , Tokyo , Japan
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Kermani TA, Warrington KJ. Advances and challenges in the diagnosis and treatment of polymyalgia rheumatica. Ther Adv Musculoskelet Dis 2014; 6:8-19. [PMID: 24489611 DOI: 10.1177/1759720x13512450] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is a common inflammatory condition that often affects people over the age of 50 years. Characteristic symptoms are shoulder and hip girdle pain and prolonged morning stiffness. Markers of inflammation are often elevated. Clinicians are often faced with the challenge of distinguishing PMR from other conditions, particularly rheumatoid arthritis and spondyloarthropathy that can mimic symptoms of PMR in older people. Additionally, there is an association between PMR and giant cell arteritis, a common large-vessel vasculitis which also affects people over the age of 50 years. Imaging of the large vessels in asymptomatic patients with PMR often reveals findings of subclinical vasculitis. Presently, there are no tests that are specific for the diagnosis of PMR and clinicians rely on a combination of history, physical examination, laboratory tests and imaging studies to make a diagnosis. A recent undertaking by the European League Against Rheumatism/American College of Rheumatology has led to the publication of provisional classification criteria of PMR. Ultrasonography, which is being increasingly used by rheumatologists, can greatly aid in the diagnosis of PMR and often shows changes of synovitis and tenosynovitis. Treatment consists of low doses of glucocorticoids which are associated with morbidity. Evaluation of newer biologic therapies targeting inflammatory cytokines is underway. Despite treatment, relapses are common.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA 90404, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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De Bandt M. Current diagnosis and treatment of polymyalgia rheumatica. Joint Bone Spine 2014; 81:203-8. [DOI: 10.1016/j.jbspin.2013.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 12/01/2022]
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Agrawal S, Bhagat SS, Dasgupta B. Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0122-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Soriano A, Landolfi R, Manna R. Polymyalgia rheumatica in 2011. Best Pract Res Clin Rheumatol 2013; 26:91-104. [PMID: 22424196 DOI: 10.1016/j.berh.2012.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/03/2012] [Accepted: 01/04/2012] [Indexed: 01/30/2023]
Abstract
Polymyalgia Rheumatica (PMR) is an inflammatory rheumatic disease that commonly affects individuals over 50 years of age, characterised by pain and morning stiffness of the shoulder and pelvic girdle. PMR can present as 'isolated' form or may be associated with giant cell arteritis. The progress of imaging techniques has helped in understanding different clinical patterns: subclinical vasculitis can occur in at least one-third of PMR patients, causing ischaemic complications. It is considered a polygenic disease and environmental factors may play a role in its pathogenesis, such as viral or bacterial triggers, both in the 'wide' form or assembled with adjuvants in vaccines. The response to steroid therapy is generally dramatic and side effects may occur, as well as the development of glucocorticoid resistance. The optimisation of therapy may require steroid-sparing agents as well as modified-release prednisone as 'nighttime' replacement therapy.
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Affiliation(s)
- Alessandra Soriano
- Clinical Autoimmunity Unit - Periodic Fever Research Centre, Catholic University of the Sacred Heart, L.go F. Vito N1, 00168 Rome, Italy
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Abstract
Polymyalgia rheumatica is a chronic, inflammatory disorder of unknown cause that affects people over age 50 years. Classic symptoms include pain and long-term morning stiffness of the neck, shoulders, hips, upper arms, and thighs. Although markers of inflammation are often raised, no specific laboratory test exists for the disorder and the diagnosis is based on clinical assessment. Provisional classification criteria were published in April, 2012, by a collaborative initiative of the European League Against Rheumatism and the American College of Rheumatology. Several other disorders can mimic polymyalgia rheumatica. In particular, clinical manifestations can be difficult to differentiate from other forms of inflammatory arthritis such as spondyloarthritis and rheumatoid arthritis. Imaging studies such as ultrasonography and MRI typically show a predominantly periarticular inflammatory process. A subset of patients has an associated inflammatory vasculopathy affecting large arteries (giant cell arteritis). The standard treatment is low-dose glucocorticoids, which provide symptomatic relief for most patients. However, disease relapses are common, and treatment with glucocorticoids is associated with substantial morbidity. Improved understanding of disease pathogenesis might allow for more targeted immunotherapy.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Schmidt J, Warrington KJ. Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management. Drugs Aging 2012; 28:651-66. [PMID: 21812500 DOI: 10.2165/11592500-000000000-00000] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged >50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged >50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized.
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Affiliation(s)
- Jean Schmidt
- Department of Internal Medicine and RECIF, Amiens University Hospital, France
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Dejaco C, Duftner C, Cimmino MA, Dasgupta B, Salvarani C, Crowson CS, Maradit-Kremers H, Hutchings A, Matteson EL, Schirmer M. Definition of remission and relapse in polymyalgia rheumatica: data from a literature search compared with a Delphi-based expert consensus. Ann Rheum Dis 2010; 70:447-53. [PMID: 21097803 PMCID: PMC3033531 DOI: 10.1136/ard.2010.133850] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To compare current definitions of remission and relapse in polymyalgia rheumatica (PMR) with items resulting from a Delphi-based expert consensus. Methods Relevant studies including definitions of PMR remission and relapse were identified by literature search in PubMed. The questionnaire used for the Delphi survey included clinical (n=33), laboratory (n=54) and imaging (n=7) parameters retrieved from a literature search. Each item was assessed for importance and availability/practicability, and limits were considered for metric parameters. Consensus was defined by an agreement rate of ≥80%. Results Out of 6031 articles screened, definitions of PMR remission and relapse were available in 18 and 34 studies, respectively. Parameters used to define remission and/or relapse included history and clinical assessment of pain and synovitis, constitutional symptoms, morning stiffness (MS), physician's global assessment, headache, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood count, fibrinogen and/or corticosteroid therapy. In the Delphi exercise a consensus was obtained on the following parameters deemed essential for definitions of remission and relapse: patient's pain assessment, MS, ESR, CRP, shoulder and hip pain on clinical examination, limitation of upper limb elevation, and assessment of corticosteroid dose required to control symptoms. Conclusions Assessment of patient's pain, MS, ESR, CRP, shoulder pain/limitation on clinical examination and corticosteroid dose are considered to be important in current available definitions of PMR remission and relapse and the present expert consensus. The high relevance of clinical assessment of hips was unique to this study and may improve specificity and sensitivity of definitions for remission and relapse in PMR.
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Affiliation(s)
- Christian Dejaco
- Correspondence to Professor Michael Schirmer, Department of Internal Medicine I, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Stone JH, Papaliodis GN, Dunbar MR, Stone JR. Case records of the Massachusetts General Hospital. Case 4-2010. A 53-year-old man with arthralgias, oral ulcers, vision loss, and vocal-cord paralysis. N Engl J Med 2010; 362:537-46. [PMID: 20147720 DOI: 10.1056/nejmcpc0910090] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- John H Stone
- Department of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, USA
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Setty AR, Robinson D. A 62-year-old man with wrist and hand pain. ARTHRITIS AND RHEUMATISM 2009; 61:132-138. [PMID: 19116980 DOI: 10.1002/art.24098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Agrawal S, Bhagat SS, Dasgupta B. Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography. Mod Rheumatol 2008; 19:53-6. [PMID: 18836893 DOI: 10.1007/s10165-008-0122-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 08/15/2008] [Indexed: 11/25/2022]
Abstract
We evaluated the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases as seen in day-to-day rheumatology practice. Data were retrieved for demography, background condition, clinical findings, indications, regions scanned, and outcomes of MSUS, and categorised as: new-patients and follow-up. New-patient records were analysed as to whether MSUS had helped to confirm or change clinical diagnosis or was of no additional help. In follow-ups, we determined whether MSUS had helped in disease assessment, detection of co-existing problems or revision of diagnosis. Its impact on treatment decisions was noted. A total of 237 patients (146 women; mean age 55.9+/-17.2 years) had 264 regions scanned; hands,50.7%. In 78/237 (32.9%) there was disagreement between clinical and MSUS findings. Amongst new-patients (72), 13/39 (33.3%) referred with inflammatory arthritis had no MSUS evidence of inflammation in or around joints. In 76.3% it helped in confirming or changing diagnosis. Of the follow-ups (165), in 78.7%, 13.9% and 7.2% it helped in assessment, detection of co-existing problems and revision of diagnosis, respectively. MSUS influenced treatment in 45/165 (27.27%) cases. In 60/67 (89.55%) cases of rheumatoid arthritis (RA), it was done for disease assessment; in 31/60 (51.66%) it influenced treatment. MSUS, as a clinic-based service in rheumatology, has significant impact on the diagnosis and treatment of patients. This has potential to reduce diagnostic uncertainty and follow-up visits and ensure better outcomes.
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Affiliation(s)
- Sumeet Agrawal
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
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Weber M, Prim J, Lüthy R. Inguinal pain with limping: Iliopectineal bursitis as first sign of polymyalgia rheumatica. Joint Bone Spine 2008; 75:332-3. [DOI: 10.1016/j.jbspin.2007.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 05/16/2007] [Indexed: 11/24/2022]
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Rabinowitz I. Polymyalgia rheumatica relapse presenting with peripheral pitting edema. Gerontology 2008; 54:157-9. [PMID: 18446045 DOI: 10.1159/000129684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 03/13/2008] [Indexed: 11/19/2022] Open
Affiliation(s)
- Israel Rabinowitz
- Department of Family Medicine, Clalit Health Services, Haifa and Western Galilee District, The Ruth & Bruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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