Management Of Polymyalgia Rheumatica Research Articles

Twenty First Century Treatments for a Nineteenth Century Disease: Polymyalgia Rheumatica

Objective: Polymyalgia Rheumatica (PMR) was first described in the 19th century in five elderly men in the Scottish spa at Strathpeffer by Dr. William Bruce [1]. The treatment of this common, painful, disabling condition has been corticosteroids virtually since these were first introduced to clinical practice 70 years ago [2]. This condition is the commonest reason for long term use of corticosteroids in the elderly. The side-effects of these agents are severe, and this is especially true in older age groups. The recent introduction of biological Disease Modifying Antirheumatic Drugs (DMARDs) and newer synthetic DMARDs has raised hope that effective treatment of PMR can be offered, and the serious side-effects of traditional steroid treatment circumvented. This review offers a summary of recent attempts to use these new antirheumatic agents. Methods: The authors searched Medline and PubMed using the search items polymyalgia rheumatica, giant cell arteritis and temporal arteritis over the past fifteen years. As much as possible, this search focused on treatment of PMR and Giant Cell Arteritis (GCA) with corticosteroids and newer synthetic and biological DMARDs where outcomes including toxicity and side-effects could be assessed. Results: The reports in the literature of the exhibition in PMR of a wide range of treatments including the newer organic and biological DMARDs have been reviewed. To date no entirely satisfactory alternative to corticosteroids for the control of this disease has been reported. Conclusion: Some of the newer DMARDs have shown promise in the management of PMR but, to date, no agent has been found adequate to replace the use of corticosteroids in the treatment of this disease.

Polymyalgia rheumatica - an up-to-date review on diagnosis and management

Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in those over the age of 50 years. Previously it was considered to be a benign clinical syndrome characterised by subacute onset bilateral shoulder and pelvic girdle pain and stiffness, with a corresponding rise in acute phase reactants, and distinctive rapid resolution of symptoms with the instigation of moderate doses of glucocorticoids. However, over the past decade, with the advancements and, indeed, wider application of imaging modalities in PMR, we have garnered an increased understanding of the anatomic predilection of inflammation and, subsequently, disease pathogenesis. Moreover, our appreciation of the relationship between PMR and giant cell arteritis (GCA) has strengthened. Glucocorticoids have formed the cornerstone of the management of PMR for decades, with often protracted treatment durations and associated high cumulative steroid burden and adverse effects. However, we are now on the cusp of a new era in the management of PMR, with our therapeutic armamentarium expanding with the recent FDA approval of the interleukin -6 antagonist sarilumab for the management of refractory disease. It is an exciting time for PMR, and this review aims to explore the recent advancements in both diagnosis and management, while also providing an updated perspective on the relationship between PMR and GCA.

Ревматическая полимиалгия в клинических рекомендациях 2018–2020 годов. Часть I. Группы риска, адъювантная терапия

В начале Декады здорового старения стал доступен ряд клинических рекомендаций по ведению ревматических болезней у пожилых. Цель публикации — характеристика и обсуждение руководства по ревматической полимиалгии Итальянского общества ревматологов (2020) и рекомендаций по применению позитронно-эмиссионной томографии/компьютерной томографии при васкулитах крупных сосудов и ревматической полимиалгии Европейской ассоциации ядерной медицины, Общества ядерной медицины и молекулярной визуализации и Американского общества ядерной кардиологии (2018). Материалы и методы. Содержание, первоисточники и методология разработки руководств изучены с помощью методов информационного анализа и сопоставлены с рекомендациями 2018–2020 гг. по ревматической полимиалгии и гигантоклеточному артерииту Европейской антиревматической лиги, Американской коллегии ревматологов, Немецкого, Австрийского, Швейцарского, Британского обществ ревматологов, Европейской федерации головной боли и их первоисточниками. Установлен приоритет консенсусного подхода в разработке современных руководств по ревматической полимиалгии. Особенность методологии создания итальянских рекомендаций состоит в сужении поиска прототипов до двух баз данных доказательной медицины и «серой» литературы и в отборе для адаптации трех руководств, включая разработку обществ ядерной медицины. Актуализированы вопросы ведения пациентов в первичном звене (предложен алгоритм), совместного принятия клинических решений, настороженности в отношении гигантоклеточного артериита. Доказательствами поддержаны лишь начальные дозы глюкокортикоидов как терапии первой линии; допускается альтернирующий режим их снижения. Обоснована неэффективность гидроксихлорохина, не обсуждается прием азатиоприна и средств альтернативной медицины. Следует установить факторы риска развития васкулита, рецидивов, длительного приема глюкокортикоидов и их побочных эффектов. Впервые для выявления васкулита рекомендовано применение позитронно-эмиссионной томографии/компьютерной томографии. Самой доказанной, сильной, согласованной является рекомендация по адъювантной терапии метотрексатом и отказу от биологических препаратов, наименее согласованной — позиция по направлению к ревматологу. Выводы. Решение такой актуальной проблемы здравоохранения, как повышение качества медицинской помощи при ревматической полимиалгии, предполагает усовершенствование медицинских стандартов по большинству клинически важных вопросов, выявление пациентов высокого риска, направление их к ревматологам и офтальмологам и рассмотрение преимуществ лечения метотрексатом.

Steroid-Sparing Effect of Tocilizumab and Methotrexate in Patients with Polymyalgia Rheumatica: A Retrospective Cohort Study.

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by pain and stiffness in the shoulders, hips, and proximal limbs; it usually affects elderly patients. The effectiveness of methotrexate and tocilizumab in PMR treatment has not been extensively studied. Thus, we aimed to assess the steroid-sparing effect of tocilizumab and methotrexate in PMR in clinical practice. Consecutive patients with PMR in our hospitals, who were included in our retrospective cohort, were reviewed between 2005 and 2015 and divided into the following groups according to their treatments: prednisolone or none (prednisolone group), methotrexate ± prednisolone (methotrexate group), or tocilizumab ± prednisolone (tocilizumab group). The prednisolone dose at the last follow-up was compared. A total of 227 patients with an average age of 74 years were enrolled. No difference in baseline characteristics was found among the three groups. The prednisolone dose at the last follow-up was lower (0 vs. 3.0 vs. 3.5 mg/day, p < 0.001) and the prednisolone discontinuation rate was higher (80.0% vs. 28.3% vs. 18.8%, p < 0.0001) in the tocilizumab group than in the prednisolone and methotrexate groups. This study suggested that tocilizumab has a steroid-sparing effect in PMR. Tocilizumab can be an option in the management of PMR. Future studies are warranted to confirm our findings.

Effect of add-on methotrexate in polymyalgia rheumatica patients flaring on glucocorticoids tapering: a retrospective study.

Guidelines on management of polymyalgia rheumatica (PMR) recommend early introduction of methotrexate (MTX), especially in patients with worse prognosis, although evidence on clinical efficacy of MTX in PMR is limited. Our objective was to assess MTX efficacy in real-world PMR care. Retrospective data of newly diagnosed PMR patients who started MTX were compared to control patients in whom MTX was not started at the first flare. Main outcomes were number of flares per year (Poisson regression) and weighted daily glucocorticoid (GC)-dose (linear regression), and flare incidence rate ratio in the MTX group only. 240 patients were selected; 39 patients in the MTX group and 201 in the control group. The yearly incidence rate ratio of flares in the MTX versus control group was 0.80 (95% CI 0.45-1.42). The yearly flare rate was 1.22 before and 0.43 after MTX initiation, resulting in an incidence ratio of 0.35 (95% CI 0.23-0.52). Adjusted time weighted daily GC dose was higher in the MTX versus control group (ratio 1.37, 95% CI 1.04-1.80). No clear effect of MTX on flares was found and time weighted daily GC dose was higher, possibly due to residual confounding by indication. However, the clearly reduced flare rate after MTX start might be suggestive for a beneficial effect of MTX.

Polymyalgia Rheumatica: a Common Disease in Seniors.

Polymyalgia rheumatica (PMR) is one of the most common inflammatory rheumatologic condition occurring in older adults. It is characterized by proximal pain and stiffness in the shoulders, neck, and/or pelvic girdle in individuals over 50years of age along with evidence of an intense systemic inflammatory response. Although the above clinical symptoms are very characteristic for the condition, it can be mimicked by other autoimmune, infectious, malignant, and endocrine disorders chief among which are giant cell arteritis (GCA) and elderly-onset rheumatoid arthritis (EORA). Recently, PMR was reported in relation to treatment with immune checkpoint inhibitors. Current treatment of PMR consists of low-to-medium doses of glucocorticosteroids (GC) with variable response rates and disease recurrence estimated to occur in 50% of patients while tapering down GC doses. In addition, GC-based regimens cause much of the morbidity associated with PMR in older adults, requiring close monitoring for GC-induced toxicity during therapy and highlighting the need for novel therapeutic strategies. Here, we review the latest findings in the field regarding specific etiologic factors, genetic associations, diagnostic methods, and advancements in treatment strategies and disease monitoring indices. Recent discoveries involving novel therapeutic targets in GCA have accelerated the study of PMR pathophysiology and have advanced treatment strategies in PMR management leading to current trials in IL-6 blocking agents. PMR remains an enigmatic inflammatory condition affecting older adults, with current treatment approach causing much morbidity in this patient population. Advancements in our understanding of novel immunopathologic targets can serve as a solid foundation for future treatment strategies in the field.

Management of polymyalgia rheumatica in older people

AbstractPolymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease affecting older people. For decades it has remained under‐researched and poorly understood, despite causing significant disability. Once thought to be a self‐limiting condition universally responsive to a limited course of prednisolone, it is now clear that most people with PMR require prolonged corticosteroids beyond two years. The cumulative burden of adverse effects from such therapy is thought to substantively contribute to reduced functionality and frailty in older patients, yet few effective alternative pharmacotherapies have been established. This review explores the latest developments regarding the effects of conventional corticosteroid treatment in PMR and the emerging potential of steroid‐sparing agents.

Pathogenesis, Diagnosis and Management of Polymyalgia Rheumatica.

Polymyalgia rheumatica is an inflammatory rheumatic disease of the elderly characterised by pain and stiffness in the neck and pelvic girdle, and is the second most common inflammatory rheumatic condition in this age group, after rheumatoid arthritis. Polymyalgia rheumatica can occur independently or in association with giant cell arteritis, which is the most common form of primary vasculitis. The diagnosis of polymyalgia rheumatica is usually based on clinical presentation and increase of inflammatory markers. There are no pathognomonic findings that can confirm the diagnosis. However, different imaging techniques, especially ultrasonography, can assist in the identification of polymyalgia rheumatica. Glucocorticoids are the cornerstone of the treatment of polymyalgia rheumatica, but they might be associated with different adverse events. A subgroup of patients presents with a refractory disease course and, in these cases, adding methotrexate as a steroid-sparing agent could be useful. In this review, we summarise the latest findings regarding the pathogenesis, diagnosis and management of polymyalgia rheumatica and try to highlight the possible pitfalls, especially in elderly patients.

Permanent Discontinuation of Glucocorticoids in Polymyalgia Rheumatica Is Uncommon but May Be Enhanced by Amino Bisphosphonates.

The duration of treatment with glucocorticoids (GC) in polymyalgia rheumatica (PMR) is often longterm. Amino bisphosphonates (N-BP) are used in PMR for the prevention of GC-induced osteoporosis, but they coulsd also have immunomodulatory properties. Whether they can be effective as an adjuvant treatment in PMR is unknown. We aimed to establish whether the use of N-BP in our PMR cohort may be associated with GC discontinuation. We conducted a retrospective review of all patients diagnosed with PMR recorded in our electronic medical notes. Cox regression analyses were used to examine the association between the use of N-BP and discontinuation of GC. Data were retrieved for 385 patients (mean age 71 ± 10 yrs, 64% females, mean initial prednisone dose 19 ± 9 mg/day). The median followup time was 38 months (range 9-57); more than 60% of patients were exposed to N-BP. GC were discontinued in 47% of patients after a median time of 20 months (range 14-27), but subsequently restarted in 39%. Overall, 276/385 patients (72%) were actively treated at their last available evaluation (mean prednisone dose 4.9 ± 5.5 mg/day), while 123/205 (60%) were still receiving GC after 24 months of followup. The use of N-BP was associated with the discontinuation of GC (adjusted HR 0.66, 95% CI 0.50-0.88), independent of age, initial GC dose, and osteoporosis. Unlike current guidelines, longterm treatment with GC is often necessary. These preliminary data suggest that N-BP may be involved in the management of PMR.

76-Year-Old Man With New Bilateral Shoulder Pain

76-Year-Old Man With New Bilateral Shoulder Pain

Diagnosis and management of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) can be a disabling condition, but the diagnosis is often delayed because many other conditions can mimic it. This article describes the recommended investigations and treatments for PMR, and discusses the GP's role in management.

S3 guidelines on treatment of polymyalgia rheumatica : Evidence-based guidelines of the German Society of Rheumatology (DGRh), the Austrian Society of Rheumatology and Rehabilitation (ÖGR) and the Swiss Society of Rheumatology (SGT) and participating medical scientific specialist societies and other organizations

Polymyalgia rheumatica (PMR) occurs almost exclusively in persons aged 50years or older and it is the second most common inflammatory rheumatic disease in older people after rheumatoid arthritis. Since there are no specific tests for PMR, the exclusion of clinically similar differential diagnoses is essential to ascertain the diagnosis. These recommendations for the management of PMR assume an already established diagnosis of PMR. It is recommended to initiate treatment with glucocorticoids immediately after diagnosis and to provide appropriate patient information and education about the impact of the disease and its treatment. Methotrexate should be considered in patients at high risk for relapse and/or glucocorticoid-related adverse events. These guidelines have been elaborated because there is significant heterogeneity in the management of PMR in clinical practice in Germany (but also Europe and worldwide), despite the large number of patients with this disease. These guidelines are primarily based on the 2015 EULAR-ACR recommendations for the management of PMR, which were updated by the guideline committee and adapted to the German speaking countries.

Polymyalgia Rheumatica and Giant Cell Arteritis

Bhaskar Dasgupta, Christian Dejaco, eds. Oxford: Oxford University Press, 2016, 192 pages, $42.50 US This first edition of Polymyalgia Rheumatica and Giant Cell Arteritis is a welcome addition to the pocket book family. The authors’ goals were to provide quick and practical updated information on the epidemiology, diagnosis, and management of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). The book is separated into 4 sections. Section 1 describes the …

REVIEW OF RECOMMENDATIONS FOR THE MANAGEMENT OF POLYMYALGIA RHEUMATICA (ACR/EULAR 2015)

Recommendations for the management of polymyalgia rheumatica are reflected in presented translation of new international guidelines (ACR/EULAR 2015).

Clinical guidelines: Best practices and uncertainties in the management of PMR.

Glucocorticoids are the mainstay of treatment for patients with polymyalgia rheumatica (PMR) and often produce substantial clinical improvements, but treatment can be complicated by relapse, adverse effects of therapies, and concomitant conditions. New recommendations aim to guide clinicians and improve the management of this disorder.

2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against...

Balancing on the edge: implications of a UK national audit of the use of BSR-BHPR guidelines for the diagnosis and management of polymyalgia rheumatica

IntroductionThe British Society for Rheumatology and British Health Professionals in Rheumatology (BSR-BHPR) guidelines for management of polymyalgia rheumatica (PMR) were published in 2010, aiming to provide guidance for diagnosis, management...

FRI0458 Current Evidence on Prognostic Factors in Patients with Polymyalgia Rheumatica (PMR): A Systematic Literature Review Informing the Acr/Eular Recommendations for the Management of PMR

BackgroundOne of the most frequent desires of patients with polymyalgia rheumatica (PMR) is to individualize their treatment based on comorbidities, co-medication and prognostic factors. The upcoming ACR/EULAR guidelines for the...

FRI0457 Current Evidence for Therapeutic Interventions in Polymyalgia Rheumatica (PMR): A Systematic Literature Review Informing the Acr/Eular Recommendations for the Management of PMR

BackgroundTreatment of Polymyalgia rheumatica (PMR) is subject to wide variations in clinical practice. We are currently developing new management guidelines for PMR for endorsement by ACR and EULAR.ObjectivesTo review the...

143. North West Regional Audit: Management of Polymyalgia Rheumatica

143. North West Regional Audit: Management of Polymyalgia Rheumatica