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Jarrot PA, Mirouse A, Ottaviani S, Cadiou S, Salmon JH, Liozon E, Parreau S, Michaud M, Terrier B, Gavand PE, Trefond L, Lavoiepierre V, Keraen J, Rekassa D, Bouldoires B, Weitten T, Roche D, Poulet A, Charpin C, Grobost V, Hermet M, Pallure M, Wackenheim C, Karkowski L, Grumet P, Rogier T, Belkefi N, Pestre V, Broquet E, Leurs A, Gautier S, Gras V, Gilet P, Holubar J, Sivova N, Schleinitz N, Durand JM, Castel B, Petrier A, Arcani R, Gramont B, Guilpain P, Lepidi H, Weiller PJ, Micallef J, Saadoun D, Kaplanski G. Polymyalgia rheumatica and giant cell arteritis following COVID-19 vaccination: Results from a nationwide survey. Hum Vaccin Immunother 2024; 20:2334084. [PMID: 38563792 PMCID: PMC10989707 DOI: 10.1080/21645515.2024.2334084] [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: 01/17/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
We conducted a national in-depth analysis including pharmacovigilance reports and clinical study to assess the reporting rate (RR) and to determine the clinical profile of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in COVID-19-vaccinated individuals. First, based on the French pharmacovigilance database, we estimated the RR of PMR and GCA cases in individuals aged over 50 who developed their initial symptoms within one month of receiving the BNT162b2 mRNA, mRNA-1273, ChAdOx1 nCoV-19, and Ad26.COV2.S vaccines. We then conducted a nationwide survey to gather clinical profiles, therapeutic management, and follow-up data from individuals registered in the pharmacovigilance study. A total of 70 854 684 COVID-19 vaccine doses were administered to 25 260 485 adults, among which, 179 cases of PMR (RR 7. 1 cases/1 000 000 persons) and 54 cases of GCA (RR 2. 1 cases/1 000 000 persons) have been reported. The nationwide survey allowed the characterization of 60 PMR and 35 GCA cases. Median time to the onset of first symptoms was 10 (range 2-30) and 7 (range 2-25) days for PMR and GCA, respectively. Phenotype, GCA-related ischemic complications and -large vessel vasculitis as well as therapeutic management and follow-up seemed similar according to the number of vaccine shots received and when compared to the literature data of unvaccinated population. Although rare, the short time between immunization and the onset of first symptoms of PMR and GCA suggests a temporal association. Physician should be aware of this potential vaccine-related phenomenon.
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Affiliation(s)
- Pierre-André Jarrot
- Department of Internal Medicine and Clinical Immunology, Hôpital de La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
- Centre for Cardiovascular and Nutrition Research (C2VN), INRA 1260, INSERM UMR_S1263, Aix-Marseille University, Marseille, France
| | - Adrien Mirouse
- Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l’Amylose inflammatoire (CEREMAIA), Sorbonne Universités, Paris, France
- INSERM, UMR_S 959 Lab, Immunology, Immunotherapeutics, Paris, France
- DMU 3ID, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Sébastien Ottaviani
- Department of Rheumatology, DMU Locomotion, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Simon Cadiou
- Department of Rheumatology, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Jean-Hugues Salmon
- Department of Rheumatology, Hôpital de La Maison Blanche, Université de Reims, Reims, France
| | - Eric Liozon
- Department of Internal Medicine, Hôpital Universitaire de Limoges, Limoges, France
| | - Simon Parreau
- Department of Internal Medicine, Hôpital Universitaire de Limoges, Limoges, France
| | - Martin Michaud
- Department of Internal Medicine, Clinique Saint-Exupery, Toulouse, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Disease, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre, Université Paris Cité, Paris, France
| | | | - Ludovic Trefond
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Virginie Lavoiepierre
- Department of Internal Medicine and Clinical Immunology, Hôpital de La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Jeremy Keraen
- Department of Internal Medicine, Hôpital de Cornouaille, Quimper, France
| | - Daniel Rekassa
- Department of Rehabilitation, Centre Thermal, Greoux Les Bains, France
| | | | - Thierry Weitten
- Department of Internal Medicine, Hôpital des Alpes du Sud, Gap, France
| | - Damien Roche
- Department of Rheumatology, Hôpital Saint-Joseph, Marseille, France
| | - Antoine Poulet
- Department of Internal Medicine, Hôpital Saint-Joseph, Marseille, France
| | - Caroline Charpin
- Department of Rheumatology, Hôpital Saint-Joseph, Marseille, France
| | - Vincent Grobost
- Department of Internal Medicine, Hôpital Estaing, Clermont-Ferrand, France
| | - Marion Hermet
- Department of Internal Medicine, Hôpital de Vichy, Vichy, France
| | - Magali Pallure
- Department of Rheumatology, Hôpital de Cannes Simone Veil, Cannes, France
| | - Chloe Wackenheim
- Department of Internal Medicine, Medipole Hôpital Privé, Villeurbanne, France
| | - Ludovic Karkowski
- Department of Internal Medicine, Hôpital d’Instruction des Armées Sainte-Anne, Toulon, France
| | - Pierre Grumet
- Department of Internal Medicine, Hôpital des Alpes du Sud, Gap, France
| | - Thomas Rogier
- Department of Internal Medicine and Systemic Disease, Hôpital François Mitterand, Dijon, France
| | - Nabil Belkefi
- Department of Internal Medicine, CH de Melun, Melun, France
| | - Vincent Pestre
- Department of Internal Medicine and Infectious Disease, CH d’Avignon, Avignon, France
| | | | - Amélie Leurs
- Department of Internal Medicine and Infectious Disease, CH de Dunkerque, Dunkerque, France
| | - Sophie Gautier
- Department of Pharmacology, centre régional de pharmacovigilance Nord Pas de Calais, CHRU de Lille, Lille, France
| | - Valérie Gras
- Department of Clinical Pharmacology, Centre régional de pharmacovigilance, service de pharmacologie clinique, CHU Amiens-Picardie, Amiens, France
| | - Pierre Gilet
- Regional Center of Pharmacovigilance, CHRU de Nancy, Hôpital Central, Nancy, France
| | - Jan Holubar
- Department of Internal Medicine, CHU de Nîmes, Nîmes, France
| | - Nadia Sivova
- Department of Internal Medicine, CH de Tourcoing, Tourcoing, France
| | - Nicolas Schleinitz
- Department of Internal Medicine, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Jean-Marc Durand
- Department of Internal Medicine, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Brice Castel
- Department of Internal Medicine, CH de Tarbes, Tarbes, France
| | | | - Robin Arcani
- Department of Internal Medicine and Therapeutics Department, Hôpital de La Timone, Marseille, France
| | - Baptiste Gramont
- Department of Internal Medicine, CHU de Saint-Etienne, Saint-Etienne, France
| | - Philippe Guilpain
- Department of Internal Medicine, CHU Saint-Eloi, Montpellier, France
| | - Hubert Lepidi
- Pathological Laboratory, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | | | - Joelle Micallef
- Department of Clinical Pharmacology and pharmacosurveillance, Regional Pharmacovigilance Center of Marseille, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - David Saadoun
- Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l’Amylose inflammatoire (CEREMAIA), Sorbonne Universités, Paris, France
- INSERM, UMR_S 959 Lab, Immunology, Immunotherapeutics, Paris, France
- DMU 3ID, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Gilles Kaplanski
- Department of Internal Medicine and Clinical Immunology, Hôpital de La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
- Centre for Cardiovascular and Nutrition Research (C2VN), INRA 1260, INSERM UMR_S1263, Aix-Marseille University, Marseille, France
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Cowley S, Harkins P, Kirby C, Conway R, Kane DJ. Should all patients with polymyalgia rheumatica have a vascular ultrasound assessment? Ann Rheum Dis 2024; 83:961-964. [PMID: 38553044 DOI: 10.1136/ard-2024-225650] [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: 02/08/2024] [Accepted: 03/19/2024] [Indexed: 07/17/2024]
Abstract
There is a growing appreciation that both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely interrelated conditions that have significant overlap in aetiology, clinical characteristics and treatment regimens. Subclinical GCA in PMR is becoming increasingly recognised, and there is evolving evidence that this may be a more aggressive disease phenotype than PMR. Ultrasound (US) lends itself well as a screening tool for GCA in PMR; it is inexpensive, non-invasive, widely available, lacks ionising radiation, may be performed at the bedside and is recommended by EULAR as a first-line investigation for suspected GCA. There is insufficient evidence to currently recommend that all patients with PMR should have a US assessment for vascular involvement. However, as clinical and laboratory parameters alone do not accurately diagnose patients with subclinical GCA, we suggest that vascular US will be increasingly performed by rheumatologists in practice to identify these patients with PMR, preferably as part of larger prospective outcome studies.
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Affiliation(s)
- Sharon Cowley
- Department of Rheumatology, Tallaght University Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - Patricia Harkins
- Trinity College Dublin, Dublin, Ireland
- Department of Rheumatology, St James Hospital, Dublin, Ireland
| | - Colm Kirby
- Department of Rheumatology, Tallaght University Hospital, Dublin, Ireland
| | - Richard Conway
- Department of Rheumatology, St James Hospital, Dublin, Ireland
| | - David J Kane
- Department of Rheumatology, Tallaght University Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
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Nielsen BD, Kristensen S, Donskov A, Terslev L, Dreyer LW, Colic A, Hetland ML, Højgaard P, Ellingsen T, Hauge EM, Chrysidis S, Keller KK. The DANIsh VASculitis cohort study: protocol for a national multicenter prospective study including incident and prevalent patients with giant cell arteritis and polymyalgia rheumatica. Front Med (Lausanne) 2024; 11:1415076. [PMID: 39026552 PMCID: PMC11256208 DOI: 10.3389/fmed.2024.1415076] [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: 04/09/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
The DANIsh VASculitis cohort study, DANIVAS, is an observational national multicenter study with the overall aim to prospectively collect protocolized clinical data and biobank material from patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) diagnosed and/or followed at Danish rheumatology departments. A long-term key objective is to investigate whether the use of new clinically implemented diagnostic imaging modalities facilitates disease stratification in the GCA-PMR disease spectrum. In particular, we aim to evaluate treatment requirements in GCA patients with and without large-vessel involvement, treatment needs in PMR patients with and without subclinical giant cell arteritis, and the prognostic role of imaging with respect to aneurysm development. Hence, in GCA and PMR, imaging stratification is hypothesized to be able to guide management strategies. With an established infrastructure within rheumatology for clinical studies in Denmark, the infrastructure of the Danish Rheumatologic Biobank, and the possibility to cross-link data with valid nationwide registries, the DANIVAS project holds an exceptional possibility to collect comprehensive real-world data on diagnosis, disease severity, disease duration, treatment effect, complications, and adverse events. In this paper, we present the research protocol for the DANIVAS study. Clinical trial registration: https://clinicaltrials.gov/, identifier NCT05935709.
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Affiliation(s)
- Berit D. Nielsen
- Department of Medicine, The Regional Hospital in Horsens, Horsens, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Salome Kristensen
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Agnete Donskov
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lene Terslev
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Wohlfahrt Dreyer
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ada Colic
- Department of Rheumatology, Zealand University Hospital, Køge, Denmark
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pil Højgaard
- Department of Medicine (2), Holbæk Hospital, Holbæk, Denmark
| | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Stavros Chrysidis
- Department of Rheumatology, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Kresten K. Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Nielsen AW, Hansen IT, Nielsen BD, Kjær SG, Blegvad-Nissen J, Rewers K, Sørensen CM, Hauge EM, Gormsen LC, Keller KK. The effect of prednisolone and a short-term prednisolone discontinuation for the diagnostic accuracy of FDG-PET/CT in polymyalgia rheumatica-a prospective study of 101 patients. Eur J Nucl Med Mol Imaging 2024; 51:2614-2624. [PMID: 38563881 PMCID: PMC11224098 DOI: 10.1007/s00259-024-06697-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE 2-[18F]Fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) has been suggested as an imaging modality to diagnose polymyalgia rheumatica (PMR). However, the applicability of FDG-PET/CT remains unclear, especially following glucocorticoid administration. This study aimed to investigate the diagnostic accuracy of FDG-PET/CT before and during prednisolone treatment, as well as following short-term prednisolone discontinuation. METHODS Treatment naïve suspected PMR patients were clinically diagnosed at baseline and subsequently had an FDG-PET/CT performed. Patients diagnosed with PMR were administered prednisolone following the first FDG-PET/CT and had a second FDG-PET/CT performed after 8 weeks of treatment. Subsequently, prednisolone was tapered with short-term discontinuation at week 9 followed by a third FDG-PET/CT at week 10. An FDG-PET/CT classification of PMR/non-PMR was applied, utilizing both the validated Leuven score and a dichotomous PMR score. The final diagnosis was based on clinical follow-up after 1 year. RESULTS A total of 68 and 27 patients received a final clinical diagnosis of PMR or non-PMR. A baseline FDG-PET/CT classified the patients as having PMR with a sensitivity/specificity of 86%/63% (Leuven score) and 82%/70% (dichotomous score). Comparing the subgroup of non-PMR with inflammatory diseases to the PMR group demonstrated a specificity of 39%/54% (Leuven/dichotomous score). After 8 weeks of prednisolone treatment, the sensitivity of FDG-PET/CT decreased to 36%/41% (Leuven/dichotomous score), while a short-term prednisolone discontinuation increased the sensitivity to 66%/60%. CONCLUSION FDG-PET/CT has limited diagnostic accuracy for differentiating PMR from other inflammatory diseases. If FDG-PET/CT is intended for diagnostic purposes, prednisolone should be discontinued to enhance diagnostic accuracy. TRIAL REGISTRATION ClinicalTrials.gov (NCT04519580). Registered 17th of August 2020.
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Affiliation(s)
- Andreas Wiggers Nielsen
- Department of Rheumatology, Aarhus University Hospital, Led- Og Bindevævssygdomme, Palle Juul-Jensens Boulevard 59, 8200, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.
| | - Ib Tønder Hansen
- Department of Rheumatology, Aarhus University Hospital, Led- Og Bindevævssygdomme, Palle Juul-Jensens Boulevard 59, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Berit Dalsgaard Nielsen
- Department of Rheumatology, Aarhus University Hospital, Led- Og Bindevævssygdomme, Palle Juul-Jensens Boulevard 59, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Søren Geill Kjær
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | | | - Kate Rewers
- Department of Nuclear Medicine and PET, Odense University Hospital, Odense, Denmark
| | | | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Led- Og Bindevævssygdomme, Palle Juul-Jensens Boulevard 59, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark
| | - Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Led- Og Bindevævssygdomme, Palle Juul-Jensens Boulevard 59, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Iorio L, Padoan R, Bond M, Dejaco C. Investigational agents for polymyalgia rheumatica treatment: assessing the critical needs for future development. Expert Opin Investig Drugs 2024; 33:671-676. [PMID: 38879822 DOI: 10.1080/13543784.2024.2366847] [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: 03/26/2024] [Accepted: 06/07/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder characterized by pain and stiffness in the shoulder and pelvic girdles, constitutional symptoms, and elevated acute-phase reactants. Glucocorticoids (GCs) remain the first-choice treatment for PMR, but relapses are common. Identification of steroid-sparing agents is therefore of utmost importance. AREAS COVERED The efficacy of conventional immunosuppressive drugs is controversial. The use of interleukin (IL)-6 receptor inhibitors proved to be effective and safe in treating PMR patients. Currently, there are 12 ongoing clinical trials exploring potential treatments such as leflunomide, low-dose IL-2, rituximab, abatacept, secukinumab, Janus kinase inhibitors, and selective inhibitors like SPI-62 and ABBV 154. EXPERT OPINION The high efficacy of IL-6 R receptor inhibitors as well as the numerous drug trials currently recruiting suggest that several therapeutic options will be available in the near future. Accurate diagnosis and early stratification of PMR patients according to the giant cell arteritis-PMR Spectrum Disease 'GPSD' and potential risk factors for relapsing disease or GC-related adverse events are crucial to identify patients who would benefit most from GC-sparing agents. The development of internationally accepted definitions for remission and relapse is urgently needed. Early referral strategies to specialist settings would improve disease stratification and personalized treatment.
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Affiliation(s)
- Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
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Wendling D, Al Tabaa O, Chevet B, Fakih O, Ghossan R, Hecquet S, Dernis E, Maheu E, Saraux A, Besson FL, Alegria GC, Cortet B, Fautrel B, Felten R, Morel J, Ottaviani S, Querellou-Lefranc S, Ramon A, Ruyssen-Witrand A, Seror R, Tournadre A, Foulquier N, Verlhac B, Verhoeven F, Devauchelle-Pensec V. Recommendations of the French Society of Rheumatology for the management in current practice of patients with polymyalgia rheumatica. Joint Bone Spine 2024; 91:105730. [PMID: 38583691 DOI: 10.1016/j.jbspin.2024.105730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To develop recommendations for the routine management of patients with polymyalgia rheumatica (PMR). METHODS Following standard procedures, a systematic review of the literature by five supervised junior rheumatologists, based on the questions selected by the steering committee (5 senior rheumatologists), was used as the basis for working meetings, followed by a one-day plenary meeting with the working group (15 members), leading to the development of the wording and determination of the strength of the recommendations and the level of agreement of the experts. RESULTS Five general principles and 19 recommendations were drawn up. Three recommendations relate to diagnosis and the use of imaging, and five to the assessment of the disease, its activity and comorbidities. Non-pharmacological therapies are the subject of one recommendation. Three recommendations concern initial treatment based on general corticosteroid therapy, five concern the reduction of corticosteroid therapy and follow-up, and two concern corticosteroid dependence and steroid-sparing treatments (anti-IL-6). CONCLUSION These recommendations take account of current data on PMR, with the aim of reducing exposure to corticosteroid therapy and its side effects in a fragile population. They are intended to be practical, to help practitioners in the day-to-day management of patients with PMR.
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Affiliation(s)
- Daniel Wendling
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France.
| | - Omar Al Tabaa
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France; Rhumatologie, Hôpital NOVO, Pontoise, France
| | - Baptiste Chevet
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Olivier Fakih
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Roba Ghossan
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France
| | | | | | - Emmanuel Maheu
- Service de rhumatologie, Hôpital St Antoine, AP-HP, et cabinet médical, Paris, France
| | - Alain Saraux
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Florent L Besson
- Service de médecine nucléaire-imagerie moléculaire, Hôpitaux universitaires Paris-Saclay AP-HP, CHU Bicêtre, DMU SMART IMAGING, Le Kremlin-Bicêtre, France
| | | | - Bernard Cortet
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | - Bruno Fautrel
- Service de rhumatologie, GH Pitié Salpêtrière, AP-HP.Sorbonne Université, INSERM UMRS 1136-5, Réseau de recherche clinique CRI-IMIDIATE, 75013 Paris, France
| | - Renaud Felten
- Service de rhumatologie et centre d'investigation clinique 1434, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jacques Morel
- Service de rhumatologie. CHU et Université de Montpellier, Montpellier, France
| | | | - Solène Querellou-Lefranc
- Nuclear Medicine department, University Hospital, Brest, France, University of Western Brittany (UBO), Brest, France, Inserm, University of Brest, CHRU Brest, UMR 1304, GETBO, Brest cedex, France
| | - André Ramon
- Service de rhumatologie, CHU Dijon Bourgogne, Dijon, France
| | - Adeline Ruyssen-Witrand
- Centre de rhumatologie, CHU de Toulouse, Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS « Pharmacologie En Population cohorteS et biobanqueS », Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Raphaèle Seror
- Service de rhumatologie, CHU Kremlin-Bicetre, AP-HP, Paris, France
| | - Anne Tournadre
- Rhumatologie CHU Clermont-Ferrand, Université Clermont Auvergne INRAe, Clermont-Ferrand, France
| | - Nathan Foulquier
- LBAI, UMR1227, University of Brest, Inserm, CHU de Brest, Brest, France
| | | | - Frank Verhoeven
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Valérie Devauchelle-Pensec
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France.
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González-Gay MÁ, Heras-Recuero E, Blázquez-Sánchez T, Caraballo-Salazar C, Rengifo-García F, Castañeda S, Largo R. Broadening the clinical spectrum of giant cell arteritis: from the classic cranial to the predominantly extracranial pattern of the disease. Expert Rev Clin Immunol 2024:1-12. [PMID: 38757894 DOI: 10.1080/1744666x.2024.2356741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Giant cell arteritis (GCA) is a large vessel (LV) vasculitis that affects people aged 50 years and older. Classically, GCA was considered a disease that involved branches of the carotid artery. However, the advent of new imaging techniques has allowed us to reconsider the clinical spectrum of this vasculitis. AREASCOVERED This review describes clinical differences between patients with the cranial GCA and those with a predominantly extracranial LV-GCA disease pattern. It highlights differences in the frequency of positive temporal artery biopsy depending on the predominant disease pattern and emphasizes the relevance of imaging techniques to identify patients with LV-GCA without cranial ischemic manifestations. The review shows that so far there are no well-established differences in genetic predisposition to GCA regardless of the predominant phenotype. EXPERT COMMENTARY The large branches of the extracranial arteries are frequently affected in GCA. Imaging techniques are useful to identify the presence of 'silent' GCA in people presenting with polymyalgia rheumatica or with nonspecific manifestations. Whether these two different clinical presentations of GCA constitute a continuum in the clinical spectrum of the disease or whether they may be related but are definitely different conditions needs to be further investigated.
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Affiliation(s)
- Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain
| | | | | | | | | | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
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8
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Fruth M, Künitz L, Martin-Seidel P, Tsiami S, Baraliakos X. MRI of shoulder girdle in polymyalgia rheumatica: inflammatory findings and their diagnostic value. RMD Open 2024; 10:e004169. [PMID: 38724260 PMCID: PMC11086571 DOI: 10.1136/rmdopen-2024-004169] [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: 01/31/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Non-synovial inflammation as detected by MRI is characteristic in polymyalgia rheumatica (PMR) with potentially high diagnostic value. OBJECTIVE The objective is to describe inflammatory MRI findings in the shoulder girdle of patients with PMR and discriminate from other causes of shoulder girdle pain. METHODS Retrospective study of 496 contrast-enhanced MRI scans of the shoulder girdle from 122 PMR patients and 374 non-PMR cases. Two radiologists blinded to clinical and demographic information evaluated inflammation at six non-synovial plus three synovial sites for the presence or absence of inflammation. The prevalence of synovial and non-synovial inflammation, both alone and together with clinical information, was tested for its ability to differentiate PMR from non-PMR. RESULTS A high prevalence of non-synovial inflammation was identified as striking imaging finding in PMR, in average 3.4±1.7, mean (M)±SD, out of the six predefined sites were inflamed compared with 1.1±1.4 (M±SD) in non-PMR group, p<0.001, with excellent discriminatory effect between PMR patients and non-PMR cases. The prevalence of synovitis also differed significantly between PMR patients and non-PMR cases, 2.5±0.8 (M±SD) vs 1.9±1.1 (M±SD) out of three predefined synovial sites, but with an inferior discriminatory effect. The detection of inflammation at three out of six predefined non-synovial sites differentiated PMR patients from controls with a sensitivity/specificity of 73.8%/85.8% and overall better performance than detection of synovitis alone (sensitivity/specificity of 86.1%/36.1%, respectively). CONCLUSION Contrast-enhanced MRI of the shoulder girdle is a reliable imaging tool with significant diagnostic value in the assessment of patients suffering from PMR and differentiation to other conditions for shoulder girdle pain.
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Affiliation(s)
- Martin Fruth
- Evidia Radiologie am Rheumazentrum Ruhrgebiet, Herne, Germany
- Rheumazentrum Ruhrgebiet, Ruhr-Universitat Bochum, Herne, Germany
| | - Lucie Künitz
- Rheumazentrum Ruhrgebiet, Ruhr-Universitat Bochum, Herne, Germany
| | | | - Styliani Tsiami
- Rheumazentrum Ruhrgebiet, Ruhr-Universitat Bochum, Herne, Germany
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Tanaka Y, Tanaka S, Fukasawa T, Inokuchi S, Uenaka H, Kimura T, Takahashi T, Kato N. Glucocorticoid treatment and clinical outcomes in patients with polymyalgia rheumatica: A cohort study using routinely collected health data. Joint Bone Spine 2024; 91:105680. [PMID: 38143016 DOI: 10.1016/j.jbspin.2023.105680] [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: 07/04/2023] [Revised: 11/15/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE We aimed to describe the following in patients with polymyalgia rheumatica (PMR): (1) real-world glucocorticoid (GC) therapy, (2) improvement in inflammatory parameters associated with disease activity (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), and (3) incidence of GC-related adverse events (AEs). METHODS A cohort study was conducted using a Japanese electronic medical records database. We included newly diagnosed PMR patients aged≥50years with baseline CRP levels≥10mg/L and/or ESR>30mm/h and an initial GC dose of≥5mg/day. The outcomes were GC dose, inflammatory parameters, and GC-related AEs. RESULTS A total of 373 PMR patients (mean age, 77.3 years) were analyzed. The median initial GC dose was 15.0mg/day, which gradually decreased to 3.5mg/day by week 52. The median cumulative GC dose at week 52 was 2455.0mg. The median CRP level on day 0 was 64.3mg/L, which decreased during weeks 4-52 (1.4-3.2mg/L). At week 52, 39.0% of patients had a CRP level>3.0mg/L. The cumulative incidence of GC-related AEs at week 52 was 49.0% for osteoporosis, 30.2% for diabetes, 14.9% for hypertension, 12.2% for peptic ulcer, 11.3% for dyslipidemia, 2.9% for glaucoma, and 4.3% for serious infection. The incidence of osteoporosis and diabetes increased with the GC dose. CONCLUSION The incidence of GC-related AEs was associated with the GC dose in PMR patients. Further research is required to identify treatment strategies that can effectively control PMR disease activity while minimizing GC use.
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Affiliation(s)
- Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555 Japan
| | - Shinichi Tanaka
- Medical Affairs Department, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006 Japan
| | - Toshiki Fukasawa
- Research and Analytics Department, Real World Data Co., Ltd., Shiseido Kyoto Bld.4F, 480, Aburanokojidori Kizuyabashi-sagaru Kitafudondocho Shimogyo-ku kyoto-shi, Kyoto, 600-8233 Japan
| | - Shoichiro Inokuchi
- Research and Analytics Department, Real World Data Co., Ltd., Shiseido Kyoto Bld.4F, 480, Aburanokojidori Kizuyabashi-sagaru Kitafudondocho Shimogyo-ku kyoto-shi, Kyoto, 600-8233 Japan
| | - Hidetoshi Uenaka
- Research and Analytics Department, Real World Data Co., Ltd., Shiseido Kyoto Bld.4F, 480, Aburanokojidori Kizuyabashi-sagaru Kitafudondocho Shimogyo-ku kyoto-shi, Kyoto, 600-8233 Japan
| | - Takeshi Kimura
- Research and Analytics Department, Real World Data Co., Ltd., Shiseido Kyoto Bld.4F, 480, Aburanokojidori Kizuyabashi-sagaru Kitafudondocho Shimogyo-ku kyoto-shi, Kyoto, 600-8233 Japan
| | - Toshiya Takahashi
- Medical Affairs Department, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006 Japan; Specialty Care Medical, Sanofi K.K., 3-20-2, Nishi-Shinjuku, Shinjuku-ku, Tokyo, 163-1488 Japan
| | - Naoto Kato
- Medical Affairs Department, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006 Japan.
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Sarı E, Gündogdu F, Semerci R. The Effect of Progressive Muscle Relaxation Exercises on Sleep Quality in Cancer Patients Undergoing Chemotherapy: A Randomized Controlled Study. Semin Oncol Nurs 2024; 40:151620. [PMID: 38494385 DOI: 10.1016/j.soncn.2024.151620] [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: 08/22/2023] [Revised: 02/07/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES This study aimed to evaluate the effect of progressive muscle relaxation exercises (PMRE) on sleep quality in patients undergoing chemotherapy treatment and experiencing disturbed sleep. METHODS The prospective randomized controlled study was conducted between March and September 2022 with 69 patients (intervention group: 34 patients, control group: 35 patients) in a hospital chemotherapy unit. During the data collection process, the "Personal Information Form" and "Pittsburgh Sleep Quality Index (PSQI)" were utilized. Patients in the intervention group performed PMRE twice a day for 8 weeks. Patients in the control group received routine care at the clinic without additional intervention. For data analysis, Student's t-test, Mann-Whitney U test, Fisher's exact test, and chi-square test were used. RESULTS The sociodemographic attributes of patients within both the intervention and control groups exhibited comparability. However, notable distinctions emerged in the PSQI Global sleep score and PSQI subdimension scores, encompassing sleep latency and duration, subjective sleep quality, habitual sleep efficiency, sleep disturbance, and daytime dysfunction between the two groups. The study found a notable difference in scores between the patients in the intervention group and those in the control group. The patients who received the intervention had significantly lower scores (P < .001). CONCLUSION The study revealed that PMRE was beneficial in improving sleep quality in cancer patients undergoing chemotherapy who had poor sleep quality. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses may consider using PMRE to improve the sleep quality of cancer patients receiving chemotherapy.
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Affiliation(s)
- Ebru Sarı
- Specialist Nurse, Konya City Hospital Medical Oncology Unit, Karatay, Konya, Türkiye
| | - Fatma Gündogdu
- Assistant Professor, Department of Nursing, KTO Karatay University, School of Health Sciences, Konya, Türkiye.
| | - Remziye Semerci
- Assistant Professor, Koç University, Nursing Faculty, Topkapı, Koç University, School of Nursing, Istanbul, Türkiye
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González-Gay MA, Heras-Recuero E, Blázquez-Sánchez T, Castañeda S, Largo R. Leflunomide as a therapeutic alternative to methotrexate as a glucocorticoid-sparing agent in polymyalgia rheumatica. Rheumatol Adv Pract 2024; 8:rkae047. [PMID: 38650634 PMCID: PMC11035002 DOI: 10.1093/rap/rkae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/25/2024] Open
Affiliation(s)
- Miguel A González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Medicine and Psychiatry Department, Universidad of Cantabria, Santander, Spain
| | | | | | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
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12
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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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13
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Nageswaran P, Ahmed S, Tahir H. Review of phase 2/3 trials in polymyalgia rheumatica and giant cell arteritis. Expert Opin Emerg Drugs 2024; 29:5-17. [PMID: 38180809 DOI: 10.1080/14728214.2024.2303093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
INTRODUCTION GCA (giant cell arteritis) and PMR (polymyalgia rheumatica) are two overlapping inflammatory rheumatic conditions that are seen exclusively in older adults, sharing some common features. GCA is a clinical syndrome characterized by inflammation of the medium and large arteries, with both cranial and extracranial symptoms. PMR is a clinical syndrome characterized by stiffness in the neck, shoulder, and pelvic girdle muscles. Both are associated with constitutional symptoms. AREAS COVERED In this review, we assess the established and upcoming treatments for GCA and PMR. We review the current treatment landscape, completed trials, and upcoming trials in these conditions, to identify new and promising therapies. EXPERT OPINION Early use of glucocorticoids (GC) remains integral to the immediate management of PMR and GCA but being aware of patient co-morbidities that may influence treatment toxicity is paramount. As such GC sparing agents are required in the treatment of PMR. Currently there are limited treatment options available for PMR and GCA, and significant unmet needs remain. Newer mechanisms of action, and hence therapeutic options being studied include CD4 T cell co-stimulation blockade, IL-17 inhibition, IL-12/23 inhibition, GM-CSF inhibition, IL-1β inhibition, TNF-α antagonist and Jak inhibition, among others, which will be discussed in this review.
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Affiliation(s)
| | - Saad Ahmed
- Department of Rheumatology, East Suffolk and North Essex Foundation Trust, Colchester, UK
| | - Hasan Tahir
- Department of Rheumatology, Royal Free London NHS Trust, London, UK
- Department of Medicine, University College London, London, UK
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14
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Camellino D, Matteson EL. Referral of patients with suspected polymyalgia rheumatica: how complete is our view of 'planet PMR?'. Ann Rheum Dis 2024:ard-2023-225217. [PMID: 38418203 DOI: 10.1136/ard-2023-225217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Affiliation(s)
- Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Italy
| | - Eric L Matteson
- Division of Rheumatology and Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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15
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De Miguel E, Karalilova R, Macchioni P, Ponte C, Conticini E, Cowley S, Tomelleri A, Monti S, Monjo I, Batalov Z, Klinowski G, Falsetti P, Kane DJ, Campochiaro C, Hočevar A. Subclinical giant cell arteritis increases the risk of relapse in polymyalgia rheumatica. Ann Rheum Dis 2024; 83:335-341. [PMID: 37932008 DOI: 10.1136/ard-2023-224768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE The aim of the present study was to determine the clinical significance of subclinical giant cell arteritis (GCA) in polymyalgia rheumatica (PMR) and ascertain its optimal treatment approach. METHODS Patients with PMR who fulfilled the 2012 European Alliance of Associations for Rheumatology/American College of Rheumatology Provisional Classification Criteria for PMR, did not have GCA symptoms and were routinely followed up for 2 years and were stratified into two groups, according to their ultrasound results: isolated PMR and PMR with subclinical GCA. The outcomes (relapses, glucocorticoid use and disease-modifying antirheumatic drug treatments) between groups were compared. RESULTS We included 150 patients with PMR (50 with subclinical GCA) with a median (IQR) follow-up of 22 (20-24) months. Overall, 47 patients (31.3 %) had a relapse, 31 (62%) in the subclinical GCA group and 16 (16%) in the isolated PMR group (p<0.001). Among patients with subclinical GCA, no differences were found in the mean (SD) prednisone starting dosage between relapsed and non-relapsed patients (32.4±15.6 vs 35.5±12.1 mg, respectively, p=0.722). Patients with subclinical GCA who relapsed had a faster prednisone dose tapering in the first 3 months compared with the non-relapsed patients, with a mean dose at the third month of 10.0±5.2 versus 15.2±7.9 mg daily (p<0.001). No differences were found between relapsing and non-relapsed patients with subclinical GCA regarding age, sex, C reactive protein and erythrocyte sedimentation rate. CONCLUSIONS Patients with PMR and subclinical GCA had a significantly higher number of relapses during a 2-year follow-up than patients with isolated PMR. Lower starting doses and rapid glucocorticoid tapering in the first 3 months emerged as risk factors for relapse.
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Affiliation(s)
| | | | | | - Cristina Ponte
- Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Sharon Cowley
- Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Irene Monjo
- Rheumatology, La Paz University Hospital, Madrid, Spain
| | - Zguro Batalov
- Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria
- Rheumatology, University Hospital Kaspela, Plovdiv, Bulgaria
| | - Giulia Klinowski
- Rheumatology Department, Ospedale S Maria Nuova, Reggio Emilia, Italy
| | - Paolo Falsetti
- Department of Medical Sciences, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Siena, Italy
| | - David J Kane
- Rheumatology, Adelaide and Meath Hospital, Dublin, Ireland
| | - Corrado Campochiaro
- Università Vita-Salute San Raffaele, School of Medicine; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Toyoda T, Armitstead Z, Bhide S, Engamba S, Henderson E, Jones C, MacKeith P, Maddock J, Reynolds G, Scrafton N, Subesinghe M, Subesinghe S, Twohig H, Mackie SL, Yates M. Treatment of polymyalgia rheumatica: British Society for Rheumatology guideline scope. Rheumatol Adv Pract 2024; 8:rkae002. [PMID: 38371294 PMCID: PMC10871769 DOI: 10.1093/rap/rkae002] [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: 09/25/2023] [Accepted: 12/28/2023] [Indexed: 02/20/2024] Open
Abstract
The last British Society for Rheumatology (BSR) guideline on PMR was published in 2009. The guideline needs to be updated to provide a summary of the current evidence for pharmacological and non-pharmacological management of adults with PMR. This guideline is aimed at healthcare professionals in the UK who directly care for people with PMR, including general practitioners, rheumatologists, nurses, physiotherapists, occupational therapists, pharmacists, psychologists and other health professionals. It will also be relevant to people living with PMR and organisations that support them in the public and third sector, including charities and informal patient support groups. This guideline will be developed using the methods and processes outlined in the BSR Guidelines Protocol. Here we provide a brief summary of the scope of the guideline update in development.
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Affiliation(s)
- Task Toyoda
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Zoe Armitstead
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sampada Bhide
- East Elmbridge Primary Care Network, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | | | - Emma Henderson
- Department of Rheumatology, Stockport NHS Foundation Trust, Stockport, UK
| | - Claire Jones
- Powys Teaching Health Board, Bronllys Hospital, Brecon, UK
| | - Pieter MacKeith
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Gary Reynolds
- Centre for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, USA
| | - Nicola Scrafton
- Department of Rheumatology, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Manil Subesinghe
- King’s College London and Guy’s and St Thomas’ PET Centre, London, UK
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Sujith Subesinghe
- Department of Rheumatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Max Yates
- Norwich Medical School, University of East Anglia, Norwich, UK
- Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Hysa E, Bond M, Ehlers L, Camellino D, Falzon L, Dejaco C, Buttgereit F, Aletaha D, Kerschbaumer A. Evidence on treat to target strategies in polymyalgia rheumatica and giant cell arteritis: a systematic literature review. Rheumatology (Oxford) 2024; 63:285-297. [PMID: 37672017 PMCID: PMC10836985 DOI: 10.1093/rheumatology/kead471] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES To inform an international task force about current evidence on Treat to Target (T2T) strategies in PMR and GCA. METHODS A systematic literature research (SLR) was conducted in Medline, EMBASE, Cochrane Library, clinicaltrials.gov from their inception date to May 2022, and in the EULAR/ACR abstract database (2019-2021). Randomised clinical trials (RCTs) and non-randomised interventional studies published in English and answering at least one of the eleven PICO questions on T2T strategies, treatment targets and outcomes, framed by the taskforce, were identified. Study selection process, data extraction and risk of bias assessment were conducted independently by two investigators. RESULTS Of 7809 screened abstracts, 397 were selected for detailed review and 76 manuscripts were finally included (31 RCTs, eight subgroup/exploratory analyses of RCTs and 37 non-randomised interventional studies). No study comparing a T2T strategy against standard of care was identified. In PMR RCTs, the most frequently applied outcomes concerned treatment (90.9% of RCTs), particularly the cumulative glucocorticoids (GC) dose and GC tapering, followed by clinical, laboratory and safety outcomes (63.3% each). Conversely, the most commonly reported outcomes in RCTs in GCA were prevention of relapses (72.2%), remission as well as treatment-related and safety outcomes (67.0% each). CONCLUSIONS This SLR provides evidence and highlights the knowledge gaps on T2T strategies in PMR and GCA, informing the task force developing T2T recommendations for these diseases.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, San Martino Polyclinic, University of Genoa, Genoa, Italy
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dario Camellino
- Division of Rheumatology, Local Health Trust 3, Genoa, Italy
| | - Louise Falzon
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Bruneck, Italy
- Department of Rheumatology, Medical University Graz, Graz, Austria
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Dejaco C, Kerschbaumer A, Aletaha D, Bond M, Hysa E, Camellino D, Ehlers L, Abril A, Appenzeller S, Cid MC, Dasgupta B, Duftner C, Grayson PC, Hellmich B, Hočevar A, Kermani TA, Matteson EL, Mollan SP, Neill L, Ponte C, Salvarani C, Sattui SE, Schmidt WA, Seo P, Smolen JS, Thiel J, Toro-Gutiérrez CE, Whitlock M, Buttgereit F. Treat-to-target recommendations in giant cell arteritis and polymyalgia rheumatica. Ann Rheum Dis 2024; 83:48-57. [PMID: 36828585 PMCID: PMC10803996 DOI: 10.1136/ard-2022-223429] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/11/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES To develop treat-to-target (T2T) recommendations in giant cell arteritis (GCA) and polymyalgia rheumatica (PMR). METHODS A systematic literature review was conducted to retrieve data on treatment targets and outcomes in GCA/PMR as well as to identify the evidence for the effectiveness of a T2T-based management approach in these diseases. Based on evidence and expert opinion, the task force (29 participants from 10 countries consisting of physicians, a healthcare professional and a patient) developed recommendations, with consensus obtained through voting. The final level of agreement was provided anonymously. RESULTS Five overarching principles and six-specific recommendations were formulated. Management of GCA and PMR should be based on shared decisions between patient and physician recognising the need for urgent treatment of GCA to avoid ischaemic complications, and it should aim at maximising health-related quality of life in both diseases. The treatment targets are achievement and maintenance of remission, as well as prevention of tissue ischaemia and vascular damage. Comorbidities need to be considered when assessing disease activity and selecting treatment. CONCLUSION These are the first T2T recommendations for GCA and PMR. Treatment targets, as well as strategies to assess, achieve and maintain these targets have been defined. The research agenda highlights the gaps in evidence and the need for future research.
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Affiliation(s)
- Christian Dejaco
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Medical University, Graz, Austria
- Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Andreas Kerschbaumer
- Abteilung für Rheumatologie, Medizinische Universitat Wien Universitatsklinik fur Innere Medizin III, Wien, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medizinische Universität Wien, Wien, Austria
| | - Milena Bond
- Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, University of Genoa, Genova, Italy
| | - Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Italy
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charite Medical Faculty Berlin, Berlin, Germany
| | - Andy Abril
- Rheumatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Simone Appenzeller
- Departamento de Clínica Médica. Facultade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
| | - Peter C Grayson
- National Institutes of Health/NIAMS, Bethesda, Maryland, USA
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatolgie und Immunologie, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - Alojzija Hočevar
- Department of Rheumatology, Universitiy Medical Centre, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tanaz A Kermani
- Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Lorna Neill
- Patient Charity Polymyalgia Rheumatica and Giant Cell Arteritis Scotland, Nethy Bridge, UK
| | - Cristina Ponte
- Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Sebastian Eduardo Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Philip Seo
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Jens Thiel
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Medical University, Graz, Austria
- Clinic for Rheumatology and Clinical Immunology, University Hospital Freiburg, Faculty of Medicine, Freiburg, UK
| | - Carlos Enrique Toro-Gutiérrez
- Reference Center in Osteoporosis, Rheumatology & Dermatology, Pontificia Universidad Javeriana Cali Facultad de Ciencias de la Salud, Cali, Colombia
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
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Vinicki JP, Gut O, Maliandi MDR, Velasco Zamora JL, Linarez M, Cusa MA, Got J, Spinetto MA, Estevez AJ, Brigante A, Curti AC, Costi AC, Cavallasca J. Risk Factors for Relapse and/or Prolonged Glucocorticoid Therapy in Polymyalgia Rheumatica: Multicenter Study in 185 Patients. J Clin Rheumatol 2024; 30:e34-e38. [PMID: 37185203 DOI: 10.1097/rhu.0000000000001969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND In polymyalgia rheumatica (PMR) relapses and long-term GC dependency are common. We assessed risk factors for higher relapse rate and/or prolonged glucocorticoid therapy in PMR patients. METHODS A multicenter and observational study (chart review) of PMR patients seen between 2006 and 2021 who had at least a 3-month follow-up period after starting GCs was performed. Results were expressed as median and interquartile range 25th-75th or mean ± standard deviation for numerical variables and percentage for categorical ones. Relapse versus nonrelapse groups were compared using Cox proportional analysis. Hazards ratios (HRs) with 95% confidence intervals (CIs) are reported. In all cases, a p value <0.05 was considered to indicate statistical significance. RESULTS We included 185 patients (69.1% female). The median follow-up time was 17.1 months (interquartile range, 6.8-34.7). Incidence of relapses was 1.2 per 100 persons/month. In univariate analysis, PMR patients with a previous history of dyslipidemia had a lower risk of relapse (HR, 0.55; 95% CI, 0.33-0.94; p = 0.03); high-dose GC (HR, 2.35; 95% CI, 1.42-3.87; p = 0.001) and faster GC dose reduction had higher risk of relapse (HR, 3.04; 95% CI, 1.77-5.21; p = 0.001). In multivariate analysis, a previous history of dyslipidemia had a lower risk of relapse (HR, 0.54; 95% CI, 0.32-0.92; p = 0.023), and high dose of GC (HR, 2.46; 95% CI, 1.49-4.08; p = 0.001) remained the only risk factors for relapse. CONCLUSIONS Lower doses of corticosteroids and a slow rate of reduction are critical to avoid relapse in PMR. Risk factors for higher relapse rate rely on therapy more than clinical characteristics of the patients at the time of diagnosis of PMR.
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Affiliation(s)
| | | | | | | | | | | | - Julio Got
- Unidad de Reumatología, Instituto Médico Humanitas, Chaco
| | | | | | | | | | | | - Javier Cavallasca
- Sección Reumatología, Hospital José Bernardo Iturraspe, Santa Fe, Argentina
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20
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Ahmed SB, Ahmad S, Pan H. Case Report and Literature Review of an Atypical Polymyalgia Rheumatica and Its Management. Int Med Case Rep J 2023; 16:873-885. [PMID: 38163043 PMCID: PMC10757773 DOI: 10.2147/imcrj.s440486] [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: 09/15/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024] Open
Abstract
Polymyalgia rheumatica (PMR) is a systemic inflammatory disease of the elderly population that increases in incidence as age advances. It is characterised by the sudden or sub-acute onset of symptoms affecting the shoulder and pelvic girdles, often accompanied by constitutional symptoms. Due to the lack of consensual diagnostic criteria and specific laboratory or radiological investigations for PMR, its diagnosis can be very challenging, particularly because it can be mimicked or masked by other geriatric syndromes. PMR responds well to glucocorticoid treatment, but if left untreated, can lead to morbidity and poor quality of life. We present the case of an 87-year-old male who presented with a one-week history of localised pain in the left hip joint, later involving the contralateral hip. Previously able to ambulate unaided, his mobility was now severely impaired. Due to his Alzheimer's dementia and multiple comorbid geriatric conditions, extensive investigations were undertaken before a diagnosis of atypical PMR was reached. Treatment with a low dose of prednisolone led to a full recovery. This case highlights the inconsistency between an atypical presentation and the classic presentation of PMR and draws attention to the possibility of missed diagnosis in older, frail patients. Atypical symptomatology on top of cognitive impairment and language barriers can be easily overlooked and left untreated and could lead to severe adverse outcomes. Accurate diagnosis is crucial, as PMR is readily diagnosed, but the treatment with glucocorticoids, though generally straightforward, can pose challenges, particularly when dealing with polypharmacy and multiple coexisting health conditions.
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Affiliation(s)
- Saad Bilal Ahmed
- Monash Health Rehabilitation and Aged Care Services, Melbourne, Australia
| | - Saara Ahmad
- Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Hanmei Pan
- Monash Health Rehabilitation and Aged Care Services, Melbourne, Australia
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21
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Tanaka Y, Tanaka S, Takahashi T, Kato N. Clinical features of polymyalgia rheumatica patients in Japan: Analysis of real-world data from 2015 to 2020. Mod Rheumatol 2023; 34:201-207. [PMID: 36881671 DOI: 10.1093/mr/road026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/19/2022] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES To assess clinical features in patients with polymyalgia rheumatica (PMR) in Japan by the International Classification of Disease (ICD)-10 code assignment. METHODS Demographics, treatment patterns, and concomitant diseases (identified using ICD-10 code only) in patients who were assigned the PMR ICD-10 code M35.3 at least once between 1 January 2015 and 31 December 2020 were aggregated from a nationwide medical information database owned by the Health, Clinic, and Education Information Evaluation Institute. RESULTS The cumulative number of patients with PMR was 6325 (mean [standard deviation] age, 74.3 [11.4] years; male:female, 1:1.3). Most patients were >50 years (96.5%) with >33% between 70 and 79 years. Glucocorticoids were prescribed in ∼54% of patients within 30 days of PMR code assignment. All other drug types were prescribed in <5% of patients. Hypertension, diabetes mellitus, rheumatoid arthritis, and osteoporosis were noted in >25% and giant cell arteritis in 1% of patients. During the study period, 4075 patients were newly assigned the PMR code and 62% were prescribed glucocorticoids within 30 days. CONCLUSIONS This is the first retrospective real-world data analysis describing the clinical features of PMR in a large patient population from Japan. Further studies of prevalence, incidence, and clinical features are warranted in patients with PMR.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shinichi Tanaka
- Medical Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | | | - Naoto Kato
- Medical Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
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22
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Nielsen AW, Hemmig AK, de Thurah A, Schmidt WA, Sattui SE, Mackie SL, Brouwer E, Dejaco C, Keller KK, Mukhtyar CB. Early referral of patients with suspected polymyalgia rheumatica - A systematic review. Semin Arthritis Rheum 2023; 63:152260. [PMID: 37639896 DOI: 10.1016/j.semarthrit.2023.152260] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Prompt diagnosis and treatment of polymyalgia rheumatica (PMR) is crucial to prevent long-term complications and improve patient outcomes. However, there is currently no standardized approach to referral of suspected PMR patients to rheumatologists, leading to inconsistent management practices. The objective of this systematic review was to clarify the existing evidence regarding the following aspects of early management strategies in patients with suspected PMR: diagnostic strategies, GCA screening, glucocorticoid initiation prior to referral, value of shared care and value of fast track clinic. METHODS Two authors performed a systematic literature search, data extraction and risk of bias assessment independently. The literature search was conducted in Embase, MEDLINE (PubMed) and Cochrane. Studies were included if they contained cohorts of suspected PMR patients and evaluated the efficacy of different diagnostic strategies for PMR, screening for giant cell arteritis (GCA), starting glucocorticoids before referral to secondary care, shared care, or fast-track clinics. RESULTS From 2,437 records excluding duplicates, 14 studies met the inclusion criteria. Among these, 10 studies investigated the diagnostic accuracy of various diagnostic strategies with the majority evaluating different clinical approaches, but none of them showed consistently high performance. However, 4 studies on shared care and fast-track clinics showed promising results, including reduced hospitalization rates, lower starting doses of glucocorticoids, and faster PMR diagnosis. CONCLUSION This review emphasizes the sparse evidence of early management and referral strategies for patients with suspected PMR. Additionally, screening and diagnostic strategies for differentiating PMR from other diseases, including concurrent GCA, require clarification. Fast-track clinics may have potential to aid patients with PMR in the future, but studies will be needed to determine the appropriate pre-referral work-up.
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Affiliation(s)
- A W Nielsen
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - A K Hemmig
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - A de Thurah
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - W A Schmidt
- Medical Centre for Rheumatology, Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus, Berlin, Germany
| | - S E Sattui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (S.E.S.)
| | - S L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, and NIHR Leeds Biomedical Research Centre, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria; Department of Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - K K Keller
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - C B Mukhtyar
- Vasculitis service, Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
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23
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Keller KK, Mukhtyar CB, Nielsen AW, Hemmig AK, Mackie SL, Sattui SE, Hauge EM, Dua A, Helliwell T, Neill L, Blockmans D, Devauchelle-Pensec V, Hayes E, Venneboer AJ, Monti S, Ponte C, De Miguel E, Matza M, Warrington KJ, Byram K, Yaseen K, Peoples C, Putman M, Lally L, Finikiotis M, Appenzeller S, Caramori U, Toro-Gutiérrez CE, Backhouse E, Oviedo MCG, Pimentel-Quiroz VR, Keen HI, Owen CE, Daikeler T, de Thurah A, Schmidt WA, Brouwer E, Dejaco C. Recommendations for early referral of individuals with suspected polymyalgia rheumatica: an initiative from the international giant cell arteritis and polymyalgia rheumatica study group. Ann Rheum Dis 2023:ard-2023-225134. [PMID: 38050004 DOI: 10.1136/ard-2023-225134] [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: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To develop international consensus-based recommendations for early referral of individuals with suspected polymyalgia rheumatica (PMR). METHODS A task force including 29 rheumatologists/internists, 4 general practitioners, 4 patients and a healthcare professional emerged from the international giant cell arteritis and PMR study group. The task force supplied clinical questions, subsequently transformed into Population, Intervention, Comparator, Outcome format. A systematic literature review was conducted followed by online meetings to formulate and vote on final recommendations. Levels of evidence (LOE) (1-5 scale) and agreement (LOA) (0-10 scale) were evaluated. RESULTS Two overarching principles and five recommendations were developed. LOE was 4-5 and LOA ranged between 8.5 and 9.7. The recommendations suggest that (1) each individual with suspected or recently diagnosed PMR should be considered for specialist evaluation, (2) before referring an individual with suspected PMR to specialist care, a thorough history and clinical examination should be performed and preferably complemented with urgent basic laboratory investigations, (3) individuals with suspected PMR with severe symptoms should be referred for specialist evaluation using rapid access strategies, (4) in individuals with suspected PMR who are referred via rapid access, the commencement of glucocorticoid therapy should be deferred until after specialist evaluation and (5) individuals diagnosed with PMR in specialist care with a good initial response to glucocorticoids and a low risk of glucocorticoid related adverse events can be managed in primary care. CONCLUSIONS These are the first international recommendations for referral of individuals with suspected PMR, which complement the European Alliance of Associations for Rheumatology/American College of Rheumatology management guidelines for established PMR.
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Affiliation(s)
- Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Andreas Wiggers Nielsen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Sarah Louise Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sebastian Eduardo Sattui
- Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | - Anisha Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Toby Helliwell
- School of Medicine, University of Staffordshire, Stafford, UK
| | - Lorna Neill
- Patient Charity Polymyalgia Rheumatica and Giant Cell Arteritis Scotland, Dundee, UK
| | - Daniel Blockmans
- Clinical Department of General Internal Medicine Department, Research Department of Microbiology and Immunology, Laboratory of Clinical Infectious and Inflammatory Disorders, University Hospitals Leuven, Leuven, Belgium
- Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
| | | | - Eric Hayes
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Annett Jansen Venneboer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sara Monti
- Rheumatology, Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia, Italy
| | - Cristina Ponte
- Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Mark Matza
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kevin Byram
- Vanderbilt Rheumatology, Vanderbilt Health, Nashville, Tennessee, USA
| | - Kinanah Yaseen
- Orthopedic and Rheumatologic Insitute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine Peoples
- Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael Putman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay Lally
- Hospital for Special Surgery, New York, New York, USA
| | - Michael Finikiotis
- University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Simone Appenzeller
- Departamento de Clínica Médica, Facultade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
| | - Ugo Caramori
- Department of Public Health, State University of Campinas, Campinas, Brazil
| | - Carlos Enrique Toro-Gutiérrez
- Reference Center in Osteoporosis, Rheumatology & Dermatology, Pontificia Universidad Javeriana Cali Facultad de Ciencias de la Salud, Cali, Colombia
| | | | | | | | | | - Claire Elizabeth Owen
- Rheumatology, Austin Health, Heidelberg, Victoria, Australia
- Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Daikeler
- Clinic for Rheumatology, University Hospital, Basel, Switzerland
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Christian Dejaco
- Rheumatology, Brunico Hospital, Brunico, Italy
- Rheumatology, Medical University of Graz, Graz, Austria
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24
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Florescu MM, Bobircă F, Florescu A, Pădureanu V, Bobircă A, Ciurea PL, Criveanu C, Florescu LM, Muşetescu AE. Polymyalgia rheumatica: An update (Review). Exp Ther Med 2023; 26:543. [PMID: 37928511 PMCID: PMC10623218 DOI: 10.3892/etm.2023.12242] [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: 04/26/2023] [Accepted: 09/05/2023] [Indexed: 11/07/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is a chronic inflammatory disease which affects the connective vascular tissue, characterized by pain accompanied by morning stiffness, predominantly of the neck muscles, hip and shoulder girdle. Usually, patients with this disease are >50 years of age and biological inflammatory syndrome is present with an increase in both the erythrocyte sedimentation rate and C-reactive protein levels, aspects similar to giant cell arteritis. The aim of the present review was to depict the current pathogenic hypothesis, diagnostic and treatment approach for patients with PMR, and novelties since the development of the currently used 2012 European League Against Rheumatism and American College of Rheumatology provisional classification criteria. PMR is a prevalent disease that can occasionally prove difficult to diagnose and treat. Possibly, the most abundant type of evidence and data revealed over the past decade have been acquired through musculoskeletal imaging, with implications in diagnosis, disease monitoring and relapse, prognosis and changes with treatment. Further research on pathophysiology is required to gain a deeper understanding of the underlying processes, which will serve as the foundation for future personalized treatments. In addition, there is an increasing demand for improved diagnostic techniques, which should include a further development of various imaging modalities, in order to provide accurate diagnosis and appropriate therapy.
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Affiliation(s)
- Mirela Marinela Florescu
- Department of Pathology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Florin Bobircă
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, 050474 Bucharest, Romania
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Vlad Pădureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Anca Bobircă
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Paulina Lucia Ciurea
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Cristina Criveanu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Anca Emanuela Muşetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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25
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Spiera RF, Unizony S, Warrington KJ, Sloane J, Giannelou A, Nivens MC, Akinlade B, Wong W, Bhore R, Lin Y, Buttgereit F, Devauchelle-Pensec V, Rubbert-Roth A, Yancopoulos GD, Marrache F, Patel N, Dasgupta B. Sarilumab for Relapse of Polymyalgia Rheumatica during Glucocorticoid Taper. N Engl J Med 2023; 389:1263-1272. [PMID: 37792612 DOI: 10.1056/nejmoa2303452] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND More than half of patients with polymyalgia rheumatica have a relapse during tapering of glucocorticoid therapy. Previous studies have suggested that interleukin-6 blockade may be clinically useful in the treatment of polymyalgia rheumatica. Sarilumab, a human monoclonal antibody, binds interleukin-6 receptor α and efficiently blocks the interleukin-6 pathway. METHODS In this phase 3 trial, we randomly assigned patients in a 1:1 ratio to receive 52 weeks of a twice-monthly subcutaneous injection of either sarilumab (at a dose of 200 mg) plus a 14-week prednisone taper or placebo plus a 52-week prednisone taper. The primary outcome at 52 weeks was sustained remission, which was defined as the resolution of signs and symptoms of polymyalgia rheumatica by week 12 and sustained normalization of the C-reactive protein level, absence of disease flare, and adherence to the prednisone taper from weeks 12 through 52. RESULTS A total of 118 patients underwent randomization (60 to receive sarilumab and 58 to receive placebo). At week 52, sustained remission occurred in 28% (17 of 60 patients) in the sarilumab group and in 10% (6 of 58 patients) in the placebo group (difference, 18 percentage points; 95% confidence interval, 4 to 32; P = 0.02). The median cumulative glucocorticoid dose at 52 weeks was significantly lower in the sarilumab group than in the placebo group (777 mg vs. 2044 mg; P<0.001). The most common adverse events with sarilumab as compared with placebo were neutropenia (15% vs. 0%), arthralgia (15% vs. 5%), and diarrhea (12% vs. 2%). More treatment-related discontinuations were observed in the sarilumab group than in the placebo group (12% vs. 7%). CONCLUSIONS Sarilumab showed significant efficacy in achieving sustained remission and reducing the cumulative glucocorticoid dose in patients with a relapse of polymyalgia rheumatica during glucocorticoid tapering. (Funded by Sanofi and Regeneron Pharmaceuticals; SAPHYR ClinicalTrials.gov number, NCT03600818.).
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Affiliation(s)
- Robert F Spiera
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Sebastian Unizony
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Kenneth J Warrington
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Jennifer Sloane
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Angeliki Giannelou
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Michael C Nivens
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Bolanle Akinlade
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Wanling Wong
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Rafia Bhore
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Yong Lin
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Frank Buttgereit
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Valerie Devauchelle-Pensec
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Andrea Rubbert-Roth
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - George D Yancopoulos
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Frederic Marrache
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Naimish Patel
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
| | - Bhaskar Dasgupta
- From the Hospital for Special Surgery, Weill Cornell Medical College, New York (R.F.S.), and Regeneron Pharmaceuticals, Tarrytown (A.G., M.C.N., B.A., R.B., G.D.Y.) - both in New York; the Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Harvard Medical School, Boston (S.U.), and Sanofi, Cambridge (J.S., N.P.) - both in Massachusetts; the Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN (K.J.W.); Sanofi, Bridgewater, NJ (W.W., Y.L.); the Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin (F.B.); CHRU de Brest, Service de Rhumatologie, Brest (V.D.-P.), and Sanofi, Chilly-Mazarin (F.M.) - both in France; the Division of Rheumatology and Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland (A.R.-R.); and Anglia Ruskin University, Cambridge, United Kingdom (B.D.)
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Aletaha D. Polymyalgia Rheumatica - from Search for Efficacy to Choice of Strategy. N Engl J Med 2023; 389:1328-1329. [PMID: 37792617 DOI: 10.1056/nejme2309384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Affiliation(s)
- Daniel Aletaha
- From the Division of Rheumatology, Medical University of Vienna, Vienna
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Conticini E, Falsetti P, d'Alessandro M, Al Khayyat SG, Grazzini S, Baldi C, Acciai C, Gentileschi S, D'Alessandro R, Bellisai F, Biasi G, Barreca C, Bargagli E, Cantarini L, Frediani B. Clinical, laboratory and ultrasonographic findings at baseline predict long-term outcome of polymyalgia rheumatica: a multicentric retrospective study : Polymyalgia rheumatica predicted by ultrasonographic findings polymyalgia rheumatica outcome predicted early by ultrasound. Intern Emerg Med 2023; 18:1929-1939. [PMID: 37498353 PMCID: PMC10543828 DOI: 10.1007/s11739-023-03373-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/10/2023] [Indexed: 07/28/2023]
Abstract
To assess the rate of PMR who, during the follow-up, undergo a diagnostic shift as well as to assess which clinical, laboratory and US findings are associated to a diagnostic shift and predict the long-term evolution of PMR. All PMR followed-up for at least 12 months were included. According to the US procedures performed at diagnosis, patients were subdivided into four subgroups. Clinical data from follow-up visits at 12, 24, 48 and 60 months, including a diagnostic shift, the number of relapses and immunosuppressive and steroid treatment, were recorded. A total of 201 patients were included. During the follow-up, up to 60% had a change in diagnosis. Bilateral LHBT was associated with persistence in PMR diagnosis, whereas GH synovitis and RF positivity to a diagnostic shift. Patients undergoing diagnostic shift had a higher frequency of GH synovitis, shoulder PD, higher CRP, WBC, PLT and Hb and longer time to achieve remission, while those maintaining diagnosis had bilateral exudative LHBT and SA-SD bursitis, higher ESR, lower Hb and shorter time to remission. Cluster analysis identified a subgroup of older patients, with lower CRP, WBC, PLT and Hb, lower PD signal or peripheral synovitis who had a higher persistence in PMR diagnosis, suffered from more flares and took more GCs. Most PMR have their diagnosis changed during follow-up. The early use of the US is associated with a lower dosage of GCs. Patients with a definite subset of clinical, laboratory and US findings seem to be more prone to maintain the diagnosis of PMR.
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Affiliation(s)
- Edoardo Conticini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Paolo Falsetti
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Miriana d'Alessandro
- Respiratory Diseases and Lung Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy.
| | - Suhel Gabriele Al Khayyat
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Silvia Grazzini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Caterina Baldi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Caterina Acciai
- Neurorehabilitation Unit, San Donato Hospital, 52100, Arezzo, Italy
| | - Stefano Gentileschi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Roberto D'Alessandro
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Francesca Bellisai
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Giovanni Biasi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Cristiana Barreca
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Luca Cantarini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 53100, Siena, Italy
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Nepal D, Putman M, Unizony S. Giant Cell Arteritis and Polymyalgia Rheumatica: Treatment Approaches and New Targets. Rheum Dis Clin North Am 2023; 49:505-521. [PMID: 37331730 DOI: 10.1016/j.rdc.2023.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Prolonged glucocorticoid tapers have been the standard of care for giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), but recent advancements have improved outcomes for patients with GCA while reducing glucocorticoid-related toxicities. Many patients with GCA and PMR still experience persistent or relapsing disease, and cumulative exposure to glucocorticoids for both diseases remains high. The objective of this review is to define current treatment approaches as well as new therapeutic targets and strategies. Studies investigating inhibition of cytokine pathways, including interleukin-6, interleukin-17, interleukin-23, granulocyte-macrophage colony-stimulating factor, Janus kinase-signal transduction and activator of transcription, and others, will be reviewed.
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Affiliation(s)
- Desh Nepal
- Department of Medicine, Division of Rheumatology, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Rheumatology, 6th Floor, Milwaukee, WI 53226, USA.
| | - Michael Putman
- Department of Medicine, Division of Rheumatology, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Rheumatology, 6th Floor, Milwaukee, WI 53226, USA
| | - Sebastian Unizony
- Massachusetts General Hospital, Vasculitis and Glomerulonephritis Center, Harvard Medical School, 55 Fruit Street, Yawkey 4B, Boston, MA 02114, USA
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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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Gu J, Yang M, Zhang B, Wang H. Efficacy of JAK Inhibitors versus DMARDs in the Treatment of Polymyalgia Rheumatica in China. Int J Gen Med 2023; 16:2981-2986. [PMID: 37465555 PMCID: PMC10350461 DOI: 10.2147/ijgm.s414267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
Objective This retrospective analysis was to assess the role of Janus kinases (JAK) inhibitors compared with conventional disease modifying anti-rheumatic drugs (DMRADs) in the treatment of polymyalgia rheumatica (PMR) with glucocorticoids (GCs) reduction. Methods Clinical information was collected from PMR patients in the JAK inhibitor group and the DMARDs group from January 2020 to August 2021 at Jiaxing first Hospital. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hemoglobin (Hb), albumin and dose of GCs before and after treatment were compared between two groups. Results Thirty female patients with PMR were included into this study. The dose of GCs in the JAK inhibitor group was significantly lower than in the DMARDs group at baseline and at 3 and 6 months after treatment. There were no significant differences in various laboratory parameters (including CRP, ESR, Hb and albumin) between two groups (P > 0.05) except that Hb in the DMARDs group was significantly higher than in the JAK inhibitor group at 3 and 6 months after treatment (P<0.05). One patient in the JAK inhibitor group developed herpes zoster, and received tofacitinib treatment after herpes zoster was relieved. Conclusion Our study indicates that JAK inhibitors in the treatment of PMR are as effective as DMRADs and are also helpful for the reduction of GCs dose.
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Affiliation(s)
- Juanfang Gu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Jiaxing University (The First Hospital of Jiaxing), Jiaxing, Zhejiang, 314300, People’s Republic of China
- Jiaxing Key Laboratory of Osteoporosis and Bone Metabolism, Jiaxing, Zhejiang, 314300, People’s Republic of China
| | - Mingfeng Yang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Jiaxing University (The First Hospital of Jiaxing), Jiaxing, Zhejiang, 314300, People’s Republic of China
- Jiaxing Key Laboratory of Osteoporosis and Bone Metabolism, Jiaxing, Zhejiang, 314300, People’s Republic of China
| | - Bin Zhang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Jiaxing University (The First Hospital of Jiaxing), Jiaxing, Zhejiang, 314300, People’s Republic of China
- Jiaxing Key Laboratory of Osteoporosis and Bone Metabolism, Jiaxing, Zhejiang, 314300, People’s Republic of China
| | - Hongzhi Wang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Jiaxing University (The First Hospital of Jiaxing), Jiaxing, Zhejiang, 314300, People’s Republic of China
- Jiaxing Key Laboratory of Osteoporosis and Bone Metabolism, Jiaxing, Zhejiang, 314300, People’s Republic of China
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Moreel L, Doumen M, Betrains A, Blockmans D, Verschueren P, Vanderschueren S. The future of polymyalgia rheumatica research: What can we learn from rheumatoid arthritis? Joint Bone Spine 2023; 90:105529. [PMID: 36690063 DOI: 10.1016/j.jbspin.2023.105529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/13/2022] [Accepted: 12/21/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Lien Moreel
- Department of General Internal Medicine, University Hospitals Leuven, 49, Herestraat, 3000 Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Michaël Doumen
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, 49, Herestraat, 3000 Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, 49, Herestraat, 3000 Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Utrecht, The Netherlands
| | - Patrick Verschueren
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, 49, Herestraat, 3000 Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Utrecht, The Netherlands
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Wendling D. Biological therapy in polymyalgia rheumatica. Expert Opin Biol Ther 2023; 23:1255-1263. [PMID: 37994867 DOI: 10.1080/14712598.2023.2287097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/20/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of the elderly, treated mainly with systemic corticosteroids. The frequency of side effects of steroids is high in this aged population and increased due to comorbidities. The use of biological treatments could be of interest in this condition. AREAS COVERED This review takes into account literature data from the PubMed and clinical trial databases concerning the results of the use of biological treatments in PMR, in terms of efficacy and safety of these treatments. EXPERT OPINION Current data do not allow us to identify any particular efficacy of the various anti-TNF agents used in the treatment of PMR. Anti-interleukin 6 agents (tocilizumab, sarilumab) have shown consistent efficacy results, suggesting a particularly interesting steroid-sparing effect in the population under consideration. The safety profile appears acceptable. Other biologic targeted treatments are currently being evaluated. Anti-interleukin-6 agents may well have a place in the therapeutic strategy for PMR, particularly for patients with steroid-resistant disease or at high risk of complications of corticosteroid therapy.
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Affiliation(s)
- Daniel Wendling
- Rheumatology, CHU (University Teaching Hospital), Besançon, France
- EA4266 EPILAB, Université de Franche-Comté, Besançon, France
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Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
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Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
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Dosoden N, Kuzuya T, Ito Y, Nishino J, Ohno E, Kawabe N, Hashimoto S, Hirooka Y, Yasuoka H. Polymyalgia rheumatica during combination therapy with atezolizumab plus bevacizumab for advanced hepatocellular carcinoma. Clin J Gastroenterol 2023:10.1007/s12328-023-01800-2. [PMID: 37071371 DOI: 10.1007/s12328-023-01800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/03/2023] [Indexed: 04/19/2023]
Abstract
The combination therapy of atezolizumab, an anti-programmed cell death ligand-1 antibody, plus bevacizumab (Atz/Bev) is widely used to treat patients with advanced hepatocellular carcinoma (HCC). The development of polymyalgia rheumatica (PMR) during immune checkpoint inhibitor therapy for patients with HCC has not been reported to date. Two patients who developed PMR during Atz/Bev therapy for advanced HCC are reported. Both patients developed fever, bilateral symmetrical shoulder pain, morning stiffness, and an elevated C-reactive protein level. Their symptoms improved rapidly with prednisolone (PSL) 15-20 mg/d, and their C-reactive protein levels decreased. In PMR, long-term low-dose PSL should be administered. In the present patients who developed PMR as immune-related adverse events, starting with a small dose of PSL resulted in rapid improvement of symptoms.
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Affiliation(s)
- Naoki Dosoden
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
| | - Yumi Ito
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Jo Nishino
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Naoto Kawabe
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Senju Hashimoto
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
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Arends S, van der Geest KS, Sandovici M. Assessment of treatment efficacy in polymyalgia rheumatica. THE LANCET. RHEUMATOLOGY 2023; 5:e171-e173. [PMID: 38251513 DOI: 10.1016/s2665-9913(23)00056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, Netherlands.
| | - Kornelis Sm van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, Netherlands
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Bolhuis TE, Marsman DE, den Broeder AA, den Broeder N, van der Maas A. 1-year results of treatment with rituximab in polymyalgia rheumatica: an extension study of a randomised double-blind placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2023; 5:e208-e214. [PMID: 38251523 DOI: 10.1016/s2665-9913(23)00032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Rituximab was effective for patients with polymyalgia rheumatica in the 21-week BRIDGE-PMR randomised controlled trial. Here, we aimed to assess rates of glucocorticoid-free remission up to 1 year after infusion in an extension of this trial. METHODS BRIDGE-PMR was a randomised controlled proof-of-concept trial that enrolled participants with polymyalgia rheumatica according to 2012 European League Against Rheumatism-American College of Rheumatology classification criteria at the Sint Maartenskliniek, Nijmegen, Netherlands. Patients were randomly allocated in a 1:1 ratio to receive one intravenous dose of 1000 mg rituximab or placebo, with identical pre-medication and accelerated glucocorticoid tapering over 17 weeks. After the 21-week study, patients were followed in a double-blind extension until 1 year after infusion during which standard-of-care treatment was provided. The primary outcome after 52 weeks was between-group difference in glucocorticoid-free remission (ie, polymyalgia rheumatica activity score [PMR-AS] <10), assessed in all randomly allocated participants, with data imputed using a predictive mean matching model (provided data were missing at random). A sensitivity analysis restricted to patients with complete data (complete case analysis) was also done. This trial is registered with EudraCT (2018-002641-11) and the Dutch trial database (NL7414). FINDINGS Between Dec 18, 2019 and June 8, 2021, 47 patients enrolled in the BRIDGE-PMR were followed up in this extension study (23 [11 women and 12 men] allocated rituximab and 24 [13 women and 11 men] allocated placebo), of who 38 had recently diagnosed polymyalgia rheumatica and nine had relapsing polymyalgia rheumatica. Mean (SD) age was 64 (10) years in the rituximab group and 66 (9) years in the placebo group. All participants were White. Missing data were imputed for six participants (four rituximab, two placebo); because the data were probably missing at random, a complete case analysis was added as sensitivity analyses. In the imputed analysis, the between-group absolute difference reached statistical significance (12 [52%] of 23 in the rituximab group in glucocorticoid-free remission vs five [21%] of 24 participants in the placebo group; absolute difference 31% [95% CI 5 to 57], RR 2·5 [1·0 to 6·0]; p=0·04). In the complete case analysis, nine (47%) of 19 patients in the rituximab group were in glucocorticoid-free remission 1 year after infusion compared with five (23%) of 22 in the placebo group (absolute difference 25% [95% CI -4 to 53], relative risk (RR) 2·1 [95% CI 0·8 to 5·2]; p=0·12). Eight (33%) patients in the placebo group and six (26%) in the rituximab group had adverse events. INTERPRETATION After a single dose of rituximab (1000 mg), the proportion of patients with polymyalgia rheumatica in glucocorticoid-free remission remained stable at 1 year after infusion, and a glucocorticoid sparing effect was evident. A larger trial including possibility for retreatment is warranted to confirm these results. FUNDING Sint Maartenskliniek.
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Affiliation(s)
- Thomas E Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Diane E Marsman
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands.
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Unmet need in the treatment of polymyalgia rheumatica and giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 36:101822. [PMID: 36907732 DOI: 10.1016/j.berh.2023.101822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
For decades, aside from prednisone and the occasional use of immune suppressive drugs such as methotrexate, there was little to offer patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, there is a great interest in various steroid sparing treatments in both these conditions. This paper aims to provide an overview of our current knowledge of PMR and GCA, examining their similarities and distinctions in terms of clinical presentation, diagnosis, and treatment, with emphasis placed on reviewing recent and ongoing research efforts on emerging treatment. Multiple recent and ongoing clinical trials are demonstrating new therapeutics that will provide benefit and contribute to the evolution of clinical guidelines and standard of care for patients with GCA and/or PMR.
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Palmowski A, Akahoshi M, Muche B, Boyadzhieva Z, Hermann S, Terao C, Wiebe E, Buttgereit F. No association between methotrexate and impaired bone mineral density in a cohort of patients with polymyalgia rheumatica, giant cell arteritis, granulomatosis with polyangiitis and other vasculitides-a cross-sectional analysis with dose-response analyses. Rheumatol Int 2023; 43:903-909. [PMID: 36811660 PMCID: PMC10073043 DOI: 10.1007/s00296-023-05286-6] [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: 12/03/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To investigate whether methotrexate (MTX) use is associated with bone mineral density (BMD) in patients with polymyalgia rheumatica (PMR) and various forms of vasculitis. METHODS Rh-GIOP is a cohort study designed to evaluate bone health in patients with inflammatory rheumatic diseases. This cross-sectional analysis assessed the baseline visits of all patients with PMR or any kind of vasculitis. Following univariable analysis, multivariable linear regression analysis was performed. The lowest T-score of either the lumbar spine or the femur was chosen as the dependent variable to examine the relationship between MTX use and BMD. These analyses were adjusted for a variety of potential confounders, including age, sex, and glucocorticoid (GC) intake. RESULTS Of 198 patients with PMR or vasculitis, 10 patients were excluded for very high GC dose (n = 6) or short disease duration (n = 4). The remaining 188 patients had the following diseases: PMR 37.2%, giant cell arteritis 25.0%, granulomatosis with polyangiitis 16.5%, followed by rarer diseases. The mean age was 68.0 ± 11.1 years, mean disease duration was 5.58 ± 6.39 years, and 19.7% had osteoporosis by dual x-ray absorptiometry (T-score ≤ -2.5). 23.4% were taking MTX at baseline with a mean dose of 13.2 mg/week (median: 15 mg/week). 38.6% of those used a subcutaneous preparation. MTX users had similar BMD compared to non-users (minimum T-scores -1.70 (± 0.86) versus -1.75 (± 0.91), respectively; p = 0.75). There was no statistically significant dose-response relationship: neither current nor cumulative dose were associated with BMD in unadjusted or adjusted models (current dose: slope -0.02; -0.14 to 0.09; p = 0.69; cumulative dose: slope -0.12; -0.28 to 0.05; p = 0.15). CONCLUSION In the Rh-GIOP cohort, MTX is used in about a quarter of patients with PMR or vasculitis. It is not associated with BMD levels.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany. .,Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark.
| | - Mitsuteru Akahoshi
- Department of Rheumatology, Faculty of Medicine, Saga University, Saga, Japan
| | - Burkhard Muche
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra Hermann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chikashi Terao
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, 230-0045, Japan
| | - Edgar Wiebe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Flores-Hidalgo A, Thompson S, Paquette D. Long-standing ulcer in mandibular gingiva in a patient with polymyalgia rheumatica. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:169-174. [PMID: 36229368 DOI: 10.1016/j.oooo.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Andres Flores-Hidalgo
- Division of Oral and Maxillofacial Pathology, East Carolina University, Greenville, NC, USA; Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA.
| | - Stevan Thompson
- Division of Oral and Maxillofacial Surgery, East Carolina University, Greenville, NC, USA; Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA
| | - David Paquette
- Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA
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Twohig H, Mitchell C, Mallen CD, Muller S. Development and psychometric evaluation of the PMR-Impact Scale: a new patient reported outcome measure for polymyalgia rheumatica. Rheumatology (Oxford) 2023; 62:758-765. [PMID: 35639659 PMCID: PMC9891434 DOI: 10.1093/rheumatology/keac317] [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: 02/26/2022] [Revised: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES PMR causes pain, stiffness and disability in older adults. Measuring the impact of the condition from the patient's perspective is vital to high-quality research and patient-centred care, yet there are no validated patient-reported outcome measures (PROMs) for PMR. We set out to develop and psychometrically evaluate a PMR-specific PROM. METHODS Two cross-sectional postal surveys of people with a confirmed diagnosis of PMR were used to provide data for field testing and psychometric evaluation. A total of 256 participants completed the draft PROM. Distribution of item responses was examined, and exploratory factor analysis and Rasch analysis were used to inform item reduction, formation of dimension structure and scoring system development. Some 179 participants completed the PROM at two time points, along with comparator questionnaires and anchor questions. Test-retest reliability, construct validity and responsiveness were evaluated. RESULTS Results from the field-testing study led to the formation of the PMR-Impact Scale (PMR-IS), comprising four domains (symptoms, function, psychological and emotional well-being, and steroid side effects). Construct validity and test-retest reliability met accepted quality criteria for each domain. There was insufficient evidence from this study to determine its ability to detect flares/deterioration, but the PMR-IS was responsive to improvements in the condition. CONCLUSION The PMR-IS offers researchers a new way to assess patient-reported outcomes in clinical studies of PMR. It has been developed robustly, with patient input at every stage. It has good construct validity and test-retest reliability. Further work is needed to fully establish its responsiveness and interpretability parameters, and to assess its real-world clinical utility.
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Affiliation(s)
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
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Diagnostic Value of Composite and Simplified FDG-PET/CT Scores in Polymyalgia Rheumatica and the Influence of Recent Glucocorticoid Treatment-A Retrospective Diagnostic Cohort Study. Diagnostics (Basel) 2023; 13:diagnostics13030514. [PMID: 36766618 PMCID: PMC9914179 DOI: 10.3390/diagnostics13030514] [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: 12/08/2022] [Revised: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
[18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) is increasingly used to demonstrate inflammation in specific sites typical for polymyalgia rheumatica (PMR). Scoring systems based on FDG uptake have been proposed to increase diagnostic accuracy. METHODS Retrospective inclusion of 198 consecutive patients ≥40 years of age referred for FDG-PET from the Department of Rheumatology. We assessed the degree of FDG uptake in predilection sites visually, as well as semiquantitatively, and through logistic regression analyses, we evaluated the performance of existing scoring systems as well as a new, simplified scoring system, against the final clinical diagnosis at 6 months after the FDG-PET scan. RESULTS We found high diagnostic accuracy for the diagnosis of PMR (range 0.74-0.91) using most of the existing scoring systems in glucocorticoid-naïve patients. A simplified scoring system including only periarticular FDG uptake in the shoulders and the ischiogluteal bursae retained high sensitivity and specificity (0.92 and 0.86, respectively). We found a detrimental effect on diagnostic accuracy in all scoring systems in patients treated with glucocorticoids within 4 weeks prior to FDG-PET. CONCLUSION Most FDG-PET scoring systems perform well for the diagnosis of PMR, and there is no loss of either sensitivity or specificity in the simplest scoring systems evaluating FDG uptake in only a few selected anatomical regions. However, systemic glucocorticoid treatment up to 4 weeks prior to FDG-PET has a markedly detrimental effect on the diagnostic accuracy of all scoring systems.
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Low C, Conway R. Metabolic bone health considerations in giant cell arteritis and polymyalgia rheumatica. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221147385. [PMID: 36627860 PMCID: PMC9837290 DOI: 10.1177/17455057221147385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two common systemic inflammatory conditions with a combined lifetime risk of approximately 3.5% in women and 1.5% in men. They are intimately associated with the aging process, virtually never occurring prior to 50 years of age and becoming more common over time. The reasons for this are unclear, but likely relate in part to factors related to aging of the immune system. The treatment of both GCA and PMR is traditionally based on glucocorticoids, frequently requiring a prolonged treatment course over long periods of time. Other medications are belatedly entering our treatment armamentarium, but their exact place in treatment algorithms remains to be fully defined and it is likely glucocorticoids will remain a cornerstone of our treatment in GCA and PMR for the foreseeable future. As a result, people with GCA and PMR will continue to be exposed to a significant cumulative glucocorticoid burden with all of the attendant potential adverse events, including osteoporosis. The predominantly post-menopausal female population that most commonly develops PMR and GCA is also the population that is most affected by osteoporosis. Given the risk of glucocorticoid-induced osteoporosis and subsequent fragility fractures, a planned treatment approach from glucocorticoid initiation is needed in these conditions. For the majority of patients, this will entail ensuring sufficiency of calcium and vitamin D as well as antiresorptive treatments. In this article, we discuss considerations around optimisation of metabolic bone health in GCA and PMR.
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Affiliation(s)
- Candice Low
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland
| | - Richard Conway
- Department of Rheumatology, St. James’s Hospital, Dublin, Ireland,Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland,Richard Conway, Department of Clinical Medicine, Trinity College Dublin, Dublin 2, Ireland.
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Colaci M, Dichiara J, Aprile ML, Ippolito M, Schinocca C, Guggino G, Malatino L. Use of 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients affected by polymyalgia rheumatica and persistent increase of acute phase reactants. Front Med (Lausanne) 2022; 9:1042620. [PMID: 36465900 PMCID: PMC9709413 DOI: 10.3389/fmed.2022.1042620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/31/2022] [Indexed: 07/28/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory disease affecting older adults characterized by aching pain and morning stiffness of the shoulder and pelvic girdles. Moreover, PMR can be associated with giant cell arteritis (GCA). Generally, PMR is highly responsive to steroids, reaching complete remission in the majority of cases. However, the possibility of occult diseases, including extra-cranial GCA, should be excluded. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) is able to detect the presence of peri-/articular or vascular inflammation, which may be both present in PMR, thus representing a useful diagnostic tool, mainly in presence of extra-cranial GCA. We retrospectively evaluated all consecutive patients who received the diagnosis of PMR in our rheumatology clinic, classified according to the 2012 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria, in the period between April 2020 and May 2022. Among this case series, we selected the patients who underwent 18F-FDG-positron emission tomography (PET) because of the persistent increase of acute phase reactants (APR) besides the steroid therapy. Eighty patients were diagnosed with PMR. Nine out of them also presented arthritis of the wrists during the follow-up, whereas none showed signs of cranial GCA at the diagnosis. Seventeen out of eighty subjects (mean age 71.5 ± 7.5 years; M/F 2/15) presented persistent increase of erythrocyte sedimentation rate (mean ESR 44.2 ± 20.8 mm/h) and/or C-reactive protein (mean CRP 25.1 ± 17 mg/l), thus they underwent total body 18F-FDG-PET/CT. Large vessel 18F-FDG uptake indicating an occult GCA was found in 5/17 (29.4%) cases. Twelve out of seventeen (70.6%) patients showed persistence of peri-/articular inflammation, suggesting a scarce control of PMR or the presence of chronic arthritis. Finally, in 2 cases, other inflammatory disorders were found, namely an acute thyroiditis and a hip prosthesis occult infection. 18F-FDG-PET/CT in PMR patients with persistent increase of APR is a useful diagnostic technique in order to detect occult GCA, persistence of active PMR or other misdiagnosed inflammatory diseases.
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Affiliation(s)
- Michele Colaci
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Jessika Dichiara
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Maria Letizia Aprile
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Massimo Ippolito
- Nuclear Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, Catania, Italy
| | - Claudia Schinocca
- Rheumatology Unit, Policlinico “P. Giaccone”, University of Palermo, Palermo, Italy
| | - Giuliana Guggino
- Rheumatology Unit, Policlinico “P. Giaccone”, University of Palermo, Palermo, Italy
| | - Lorenzo Malatino
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
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44
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Mukhtyar CB, Twohig H, Hodgson H. Getting it right for polymyalgia rheumatica. Rheumatology (Oxford) 2022; 61:4221-4222. [PMID: 35311988 DOI: 10.1093/rheumatology/keac187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/16/2022] [Indexed: 10/12/2023] Open
Affiliation(s)
- Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich
| | - Helen Twohig
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele
| | - Humphrey Hodgson
- Polymyalgia Rheumatica & Giant Cell Arteritis UK, London, UK
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45
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Sattui SE, Jannat-Khah D, Lally L, Lieber SB, Mandl LA, Spiera RF. Prevalence of frailty in patients with polymyalgia rheumatica and association with health-related quality of life, cognition and sarcopenia. Rheumatology (Oxford) 2022; 61:4455-4464. [PMID: 35136992 PMCID: PMC9629413 DOI: 10.1093/rheumatology/keac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/17/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To describe the prevalence of frailty in a single-centre cohort of patients with PMR and describe its association with health-related quality of life (HRQoL), cognition and sarcopenia. METHODS This was a cross-sectional study of patients with PMR, according to 2012 EULAR/ACR Classification Criteria, presenting within 12 months of diagnosis and on treatment with glucocorticoids. Frailty was defined according to the Fried frailty criteria. HRQoL was assessed using Patient-Reported Outcomes Measurement Information System Computerized Adaptive Test (PROMIS-CAT) and cognition was assessed using the Mini-Mental State Examination. Sarcopenia was measured by DXA. RESULTS Forty-one patients were enrolled. Prevalence of frailty and pre-frailty was 17% and 59%, respectively. Frail patients had higher inflammatory markers at diagnosis compared with pre-frail and robust patients. Of 27 patients with DXA results, 26% were sarcopenic. Frail patients had worse physical function, and more pain behaviour and interference compared with pre-frail and robust patients. In univariable analyses, frail patients were more likely to have worse physical function, and more pain behaviour and pain interference, which remained significant after adjusting for age. There were no significant associations between cognition or sarcopenia and frailty. CONCLUSIONS In this cohort of PMR patients, there was a higher prevalence of frailty and pre-frailty compared with that reported in community-dwelling elderly. Frailty was associated with worse physical function, and increased pain behaviour and pain interference, differences that were also clinically meaningful. Larger prospective studies are needed to confirm these findings and analyse the association of frailty with other PMR disease outcomes.
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Affiliation(s)
- Sebastian E Sattui
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Deanna Jannat-Khah
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lindsay Lally
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Sarah B Lieber
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lisa A Mandl
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert F Spiera
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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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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47
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Devauchelle-Pensec V, Carvajal-Alegria G, Dernis E, Richez C, Truchetet ME, Wendling D, Toussirot E, Perdriger A, Gottenberg JE, Felten R, Fautrel BJ, Chiche L, Hilliquin P, Le Henaff C, Dervieux B, Direz G, Chary-Valckenaere I, Cornec D, Guellec D, Marhadour T, Nowak E, Saraux A. Effect of Tocilizumab on Disease Activity in Patients With Active Polymyalgia Rheumatica Receiving Glucocorticoid Therapy: A Randomized Clinical Trial. JAMA 2022; 328:1053-1062. [PMID: 36125471 DOI: 10.1001/jama.2022.15459] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Few treatments are available for patients with glucocorticoid-dependent polymyalgia rheumatica. IL-6 antagonists may reduce disease activity in patients with active glucocorticoid-dependent polymyalgia rheumatica. OBJECTIVE To compare the efficacy of tocilizumab vs placebo in patients with glucocorticoid-dependent polymyalgia rheumatica. DESIGN, SETTING, AND PARTICIPANTS This double-blind, parallel-group, placebo-controlled randomized clinical trial enrolled 101 patients with polymyalgia rheumatica at 17 hospitals in France from February 2017 to October 2019. Final follow-up occurred in November 2020. Inclusion criteria were persistent disease activity (polymyalgia rheumatica activity score computed using the C-reactive protein level [CRP PMR-AS] >10) and prednisone dose greater than or equal to 10 mg per day. INTERVENTIONS Patients were randomly assigned to receive intravenous tocilizumab (8 mg/kg; n = 51) or placebo (n = 50) every 4 weeks for 24 weeks, combined with predefined standardized tapering of oral prednisone. MAIN OUTCOMES AND MEASURES The primary efficacy end point was CRP PMR-AS less than 10 (range, 0-100; higher values indicate greater activity; no minimal clinically important difference defined) combined with either prednisone dose less than or equal to 5 mg per day or a decrease in prednisone dose greater than or equal to 10 mg from baseline at week 24. There were 11 secondary outcomes assessed at week 24 included in this report, including disease activity (measured by CRP PMR-AS) and the proportion of patients no longer taking prednisone. RESULTS Of the 101 randomized patients (mean age, 67.2 years; 68 [67.3%] women), 100 (99%) received at least 1 infusion and 100 completed the trial. The primary end point was achieved in 67.3% of patients in the tocilizumab group and 31.4% of patients in the placebo group (adjusted difference, 36.0% [95% CI, 19.4%-52.6%]; adjusted relative risk, 2.3 [95% CI, 1.5-3.6]; P < .001). Of 11 reported secondary end points at 24 weeks, 7 showed significant differences favoring tocilizumab, including mean CRP PMR-AS score (7.5 [95% CI, 5.4-9.6] vs 14.9 [95% CI, 11.4-18.4]; adjusted difference, -7.5 [95% CI, -11.2 to -3.8]; P < .001) and the percentage of patients no longer receiving prednisone (49.0% vs 19.6%; adjusted difference, 29.3% [95% CI, 18.9%-39.7%]; adjusted relative risk, 2.5 [95% CI, 1.8-3.5]; P < .001). The most frequent adverse events were infections, experienced by 23 patients (46.9%) in the tocilizumab group and 20 (39.2%) in the placebo group. CONCLUSIONS AND RELEVANCE Among patients with active polymyalgia rheumatica despite prednisone therapy, tocilizumab, compared with placebo, resulted in a significantly greater percentage of patients with a CRP PMR-AS less than 10 with reduced prednisone requirements at week 24. Further research is needed to confirm efficacy and to determine the balance of potential benefits and harms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02908217.
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Affiliation(s)
- Valérie Devauchelle-Pensec
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | - Guillermo Carvajal-Alegria
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | | | - Christophe Richez
- Rheumatology Department, Bordeaux University Hospital and Bordeaux University, Bordeaux, France
| | - Marie-Elise Truchetet
- Rheumatology Department, Bordeaux University Hospital and Bordeaux University, Bordeaux, France
| | - Daniel Wendling
- Rheumatology Department, Besançon Regional University Hospital and Bourgogne Franche-Comté University, Besançon, France
| | - Eric Toussirot
- INSERM CIC-1431 Clinical Investigations Center, Besançon University Hospital Besançon, France
| | - Aleth Perdriger
- Rennes 1 University, School of Medicine, South Hospital, Rheumatology Department, Rennes, France
| | | | - Renaud Felten
- Department of Rheumatology, Strasbourg University Hospitals, Strasbourg, France
| | - Bruno Jean Fautrel
- Sorbonne Université - Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière Hospital, Rheumatology Department, Paris, France
| | - Laurent Chiche
- Internal Medicine Department, European Hospital, Marseille, France
| | - Pascal Hilliquin
- Department of Rheumatology, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | | | | | - Guillaume Direz
- Rheumatology Department, Community Hospital, Le Mans, France
| | | | - Divi Cornec
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
| | - Dewi Guellec
- Clinical Investigations Centre (CIC) 1412, National Health and Medical Research Institute (INSERM), Brest, France
| | | | - Emmanuel Nowak
- Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
| | - Alain Saraux
- Rheumatology Department, Brest University Hospital, Brest, France
- INSERM 1227, Brest University, Brest, France
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Bolhuis TE, Marsman D, van den Hoogen FHJ, Broeder AAD, Broeder ND, van der Maas A. (Dis)agreement of polymyalgia rheumatica relapse criteria, and prediction of relapse in a retrospective cohort. BMC Rheumatol 2022; 6:45. [PMID: 35915465 PMCID: PMC9344672 DOI: 10.1186/s41927-022-00274-y] [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: 12/07/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background To develop and assess a prediction model for polymyalgia rheumatica (PMR) relapse within the first year of glucocorticoid (GC) treatment. Methods A retrospective PMR cohort (clinical diagnosis) from a rheumatology department was used. All visits > 30 days after starting GC treatment and with > 2.5 mg/day oral prednisolone were used as potential relapse visits. Often used relapse criteria (1) rheumatologist judgement, (2) treatment intensification-based relapse) were assessed for agreement in this cohort. The proportion of patients with treatment-based relapse within 1 and 2 years of treatment and the relapse incidence rate were used to assess unadjusted associations with candidate predictors using logistic and Poisson regression respectively. After using a multiple imputation method, a multivariable model was developed and assessed to predict the occurrence (yes/no) of relapse within the first year of treatment. Results Data from 417 patients was used. Relapse occurred at 399 and 321 (of 2422) visits based on the rheumatologist judgement- and treatment-based criteria respectively, with low to moderate agreement between the two (87% (95% CI 0.86–0.88), with κ = 0.49 (95% CI 0.44–0.54)). Treatment-based relapse within the first two years was significantly associated with CRP, ESR, and pre-treatment symptom duration, and incidence rate with only CRP and ESR. A model to predict treatment intensification within the first year of treatment was developed using sex, medical history of cardiovascular disease and malignancies, pre-treatment symptom duration, ESR, and Hb, with an AUC of 0.60–0.65. Conclusion PMR relapse occurs frequently, although commonly used criteria only show moderate agreement, underlining the importance of a uniform definition and criteria of a PMR specific relapse. A model to predict treatment intensification was developed using practical predictors, although its performance was modest. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00274-y.
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Affiliation(s)
- Thomas E Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands. .,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Diane Marsman
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
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49
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Subclinical giant cell arteritis in new onset polymyalgia rheumatica A systematic review and meta-analysis of individual patient data. Semin Arthritis Rheum 2022; 55:152017. [DOI: 10.1016/j.semarthrit.2022.152017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 01/18/2023]
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50
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Borresen SW, Klose M, Glintborg D, Watt T, Andersen MS, Feldt-Rasmussen U. Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2022; 107:2065-2076. [PMID: 35302603 DOI: 10.1210/clinem/dgac151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 11/19/2022]
Abstract
Glucocorticoid-induced adrenal insufficiency is caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis and is the most prevalent form of adrenal insufficiency. The condition is important to diagnose given the risk of life-threatening adrenal crisis and impact on patients' quality of life. The diagnosis is made with a stimulation test such as the ACTH test. Until now, testing for glucocorticoid-induced adrenal insufficiency has often been based on clinical suspicion rather than routinely but accumulating evidence indicates that a significant number of cases will remain unrecognized. During ongoing oral glucocorticoid treatment or initially after withdrawal, ~50% of patients have adrenal insufficiency, but, outside clinical studies, ≤ 1% of patients have adrenal testing recorded. More than 70% of cases are identified during acute hospital admission, where the diagnosis can easily be missed because symptoms of adrenal insufficiency are nonspecific and overlap those of the underlying and intercurrent conditions. Treatment of severe glucocorticoid-induced adrenal insufficiency should follow the principles for treatment of central adrenal insufficiency. The clinical implications and thus indication to treat mild-moderate adrenal deficiency after glucocorticoid withdrawal has not been established. Also, the indication of adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear. In patients with established glucocorticoid-induced adrenal insufficiency, high rates of poor confidence in self-management and delayed glucocorticoid administration in the acute setting with an imminent adrenal crisis call for improved awareness and education of clinicians and patients. This article reviews different facets of glucocorticoid-induced adrenal insufficiency and discusses approaches to the condition in common clinical situations.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Torquil Watt
- Department of Endocrinology and Internal Medicine, Herlev and Gentofte Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marianne Skovsager Andersen
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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