Assessment of 2012 EULAR/ACR new classification criteria for polymyalgia rheumatica in Japanese patients diagnosed using Bird's criteria

Diagnostic performance of the 2012 EULAR/ACR classification criteria for polymyalgia rheumatica in Korean patients

AIM

This prospective study aimed to evaluate the diagnostic performance of the 2012 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) classification criteria for polymyalgia rheumatica (PMR) compared to that of previous classification/diagnostic criteria in the Korean population.

METHOD

We consecutively included 77 patients aged ≥50 years presenting with bilateral shoulder pain and elevated acute-phase reactants. All patients were evaluated for fulfillment of each of the 5 different criteria for PMR (Chuang et al, Bird, Jones and Hazleman, Healey, and the EULAR/ACR criteria). At baseline, bilateral ultrasound (US) examinations of the shoulders and hips were performed. Final diagnosis was made by an experienced rheumatologist at the 12-month follow-up. The area under the curve (AUC), sensitivity, and specificity of criteria sets were assessed.

RESULTS

At the end of follow-up, 38 and 39 patients were diagnosed with PMR and non-PMR including rheumatoid arthritis (RA, n = 20), respectively. The EULAR/ACR classification criteria with US showed the best discriminating capacity (AUC 0.843). Adding US to EULAR/ACR criteria increased specificity from 74.4% to 89.7%, but decreased sensitivity from 89.5% to 78.9%. The two US items of the EULAR/ACR criteria were significantly more frequent in patients with PMR than in controls. However, the second criterion consisting of both shoulders inflamed were similar between PMR (60.5%) and RA (60.0%) groups.

CONCLUSION

The 2012 EULAR/ACR classification criteria for PMR performed best in classifying PMR from other inflammatory and non-inflammatory disorders with shoulder pain in Asian populations.

Shoulder ultrasound and serum lactate dehydrogenase predict inadequate response to glucocorticoid treatment in patients with polymyalgia rheumatica

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.

Application of 2012 EULAR/ACR criteria for polymyalgia rheumatica to Korean patients previously classified by Chuang and Hunder criteria or Healey criteria

AIM

To apply 2012 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) criteria to Korean patients previously classified as polymyalgia rheumatica (PMR) by Chuang and Hunder criteria or Healey criteria and investigated whether they might be still reclassified as PMR or not.

METHODS

We retrospectively reviewed the medical records of 113 previously classified PMR patients. We applied 2012 EULAR/ACR criteria without ultrasonography to PMR patients, and fulfilment required at least 4 points. We evaluated odds ratios (OR) using logistic regression analyses.

RESULTS

The mean age was 61.7 years. Seventy-one patients (62.8%) fulfilled Chuang and Hunder criteria, and 113 patients (100%) met Healey criteria. When we applied 2012 EULAR/ACR criteria, 98 patients fulfilled essential items (≥50 years, bilateral shoulder aching and abnormal C-reactive protein or erythrocyte sedimentation rate), and only 80 patients achieved points ≥4. Eight patients fulfilling the criteria exhibited higher frequencies of all the detailed items than those who did not. In multivariate logistic regression analysis, absence of rheumatoid factor or anti-citrullinated peptide antibodies was the only independent contributing item to the fulfilment of 2012 EULAR/ACR criteria (OR 23.571, 95% CI 6.357-87.407, P < .001). When we reclassified 33 excluded patients, the most common newly classified disease was generalized osteoarthritis (24.2%), followed by osteoporosis with compression fracture (15.2%).

CONCLUSION

Eighty of 113 patients (81.6%) previously classified by Chuang and Hunder criteria or Healey criteria fulfilled 2012 EULAR/ACR criteria for PMR.

Polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory disease that affects the shoulder, the pelvic girdles, and the neck, usually in individuals older than 50 years. Increases in acute phase reactants are typical of polymyalgia rheumatica. The disorder might present as an isolated condition or in association with giant cell arteritis. Several diseases, including inflammatory rheumatic and autoimmune diseases, infections, and malignancies can mimic polymyalgia rheumatica. Imaging techniques have identified the presence of bursitis in more than half of patients with active disease. Vascular uptake on PET scans is seen in some patients. A dose of 12·5-25·0 mg prednisolone daily or equivalent leads to rapid improvement of symptoms in most patients with isolated disease. However, relapses are common when prednisolone is tapered. Methotrexate might be used in patients who relapse. The effectiveness of biological therapies, such as anti-interleukin 6, in patients with polymyalgia rheumatica that is refractory to glucocorticoids requires further investigation. Most population-based studies indicate that mortality is not increased in patients with isolated disease.