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Annals of the Rheumatic Diseases Jan 2024To develop treat-to-target (T2T) recommendations in giant cell arteritis (GCA) and polymyalgia rheumatica (PMR).
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.
Topics: Humans; Giant Cell Arteritis; Polymyalgia Rheumatica; Quality of Life; Comorbidity
PubMed: 36828585
DOI: 10.1136/ard-2022-223429 -
Deutsches Arzteblatt International Jun 2022Polymyalgia rheumatica (PMR) is among the most common inflammatory rheumatic diseases in older adults. Presumed risk factors include female sex, previous infections, and... (Review)
Review
BACKGROUND
Polymyalgia rheumatica (PMR) is among the most common inflammatory rheumatic diseases in older adults. Presumed risk factors include female sex, previous infections, and genetic factors. No epidemiological data on PMR in Germany have been available until now.
METHODS
This review is based on publications retrieved by a selective literature search in PubMed. Moreover, the administrative incidence and prevalence of PMR in the years 2011-2019 was determined from data of the AOK Baden-Württemberg statutory health insurance carrier for insurees aged 40 and older. In addition, we quantified the number of consultations with physicians involved in the diagnosis.
RESULTS
The annual age- and sex-standardized incidence and prevalence of PMR from 2011 to 2019 were 18.6/100 000 persons and 138.8/100 000 persons, respectively. The incidence was higher in women than in men (21.8/100 000 vs. 12.8/100 000 persons per year). 60% of the cases were diagnosed in primary care practices. The treatment of PMR with orally administered glucocorticoids usually results in a treatment response within a few days to weeks. Approximately 43% of patients experience recurrent symptoms within a year, requiring adjustment of the glucocorticoid dose. For older patients with impaired physical ability, additional non-pharmacological treatment with exercise programs plays an important role.
CONCLUSION
PMR usually takes an uncomplicated course under treatment and can be managed in primary care, but these patients are often multimorbid and require frequent follow-up. Along with research on the etiology of the disease, further studies are needed to identify the risk factors for a chronic course and to evaluate the potential effects of non-pharmacological measures.
Topics: Adult; Aged; Female; Giant Cell Arteritis; Glucocorticoids; Humans; Incidence; Male; Middle Aged; Polymyalgia Rheumatica; Prevalence
PubMed: 35635433
DOI: 10.3238/arztebl.m2022.0218 -
Annals of Internal Medicine May 2017This issue provides a clinical overview of polymyalgia rheumatica, focusing on risk factors, diagnosis, treatment, and practice improvement. The content of In the Clinic... (Review)
Review
This issue provides a clinical overview of polymyalgia rheumatica, focusing on risk factors, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
Topics: Diagnosis, Differential; Glucocorticoids; Humans; Immunosuppressive Agents; Patient Education as Topic; Polymyalgia Rheumatica; Prognosis; Risk Factors
PubMed: 28460395
DOI: 10.7326/AITC201705020 -
Nature Reviews. Rheumatology Jul 2023Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature,... (Review)
Review
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.
Topics: Humans; Giant Cell Arteritis; Polymyalgia Rheumatica; Glucocorticoids; Diagnostic Imaging
PubMed: 37308659
DOI: 10.1038/s41584-023-00976-8 -
Annals of the Rheumatic Diseases Jun 2022Polymyalgia rheumatica is the second most common inflammatory rheumatic disease of people >50 years. Glucocorticoid therapy is highly effective, but many patients... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Polymyalgia rheumatica is the second most common inflammatory rheumatic disease of people >50 years. Glucocorticoid therapy is highly effective, but many patients require treatment for several years. Effective glucocorticoid sparing agents are still needed.
METHODS
In this double-blind, multi-centre phase 2/3 clinical trial, we randomly assigned 36 patients with new onset polymyalgia rheumatica from three centres to receive subcutaneous tocilizumab (162 mg per week) or placebo for 16 weeks (1:1 ratio). All patients received oral prednisone, tapered from 20 mg to 0 mg over 11 weeks.The primary endpoint was the proportion of patients in glucocorticoid-free remission at week 16; key secondary endpoints, including time to first relapse and cumulative glucocorticoid dose at weeks 16 and 24, were evaluated.
RESULTS
From 20 November 2017 to 28 October 2019 39 patients were screened for eligibility; 19 patients received tocilizumab and 17 placebo. Glucocorticoid-free remission at week 16 was achieved in 12 out of 19 patients on tocilizumab (63.2%) and 2 out of 17 patients receiving placebo (11.8%, p=0.002), corresponding to an OR of 12.9 (95 % CI: 2.2 to 73.6) in favour of tocilizumab. Mean (±SD) time to first relapse was 130±13 and 82±11 days (p=0.007), respectively, and the median (IQR) cumulative glucocorticoid dose was 727 (721-842) mg and 935 (861-1244) mg (p=0.003), respectively. Serious adverse events were observed in five placebo patients and one tocilizumab patient.
CONCLUSION
In patients with new onset polymyalgia rheumatica undergoing rapid glucocorticoid tapering, tocilizumab was superior to placebo regarding sustained glucocorticoid-free remission, time to relapse and cumulative glucocorticoid dose.
TRIAL REGISTRATION NUMBER
NCT03263715.
Topics: Antibodies, Monoclonal, Humanized; Drug Administration Schedule; Giant Cell Arteritis; Glucocorticoids; Humans; Polymyalgia Rheumatica; Recurrence; Treatment Outcome
PubMed: 35210264
DOI: 10.1136/annrheumdis-2021-221126 -
Annals of the Rheumatic Diseases Oct 2015Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this...
Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients' and clinicians' values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.
Topics: Algorithms; Antirheumatic Agents; Biomedical Research; Disease Management; Drug Administration Schedule; Evidence-Based Medicine; Glucocorticoids; Humans; International Cooperation; Phytotherapy; Polymyalgia Rheumatica
PubMed: 26359488
DOI: 10.1136/annrheumdis-2015-207492 -
Expert Opinion on Biological Therapy 2023Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of the elderly, treated mainly with systemic corticosteroids. The frequency of side effects of steroids... (Review)
Review
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.
Topics: Aged; Humans; Polymyalgia Rheumatica; Tumor Necrosis Factor Inhibitors; Giant Cell Arteritis; Glucocorticoids; Biological Therapy; Steroids
PubMed: 37994867
DOI: 10.1080/14712598.2023.2287097 -
Rheumatology (Oxford, England) Nov 2022
Topics: Humans; Polymyalgia Rheumatica; Giant Cell Arteritis; Diagnosis, Differential
PubMed: 35311988
DOI: 10.1093/rheumatology/keac187 -
Best Practice & Research. Clinical... Mar 2023Rheumatologists are increasingly using vascular ultrasound. Several guidelines now recommend ultrasound as the first diagnostic modality in giant cell arteritis (GCA).... (Review)
Review
Rheumatologists are increasingly using vascular ultrasound. Several guidelines now recommend ultrasound as the first diagnostic modality in giant cell arteritis (GCA). The German curriculum for rheumatology training has recently included ultrasound for the acute diagnosis of vasculitis. Recent studies have shown that ultrasound of temporal, axillary, subclavian, and vertebral arteries has sensitivities and specificities of >90%. Vascular ultrasound detects subclinical GCA in approximately 20% of patients with "pure" polymyalgia rheumatica. GCA fast-track clinics might regularly include these patients. A new score based on the intima-media thickness of the temporal and axillary arteries allows the monitoring of structural changes with treatment. The score decreases faster for the temporal arteries than it does for the axillary arteries. Measuring the diameter of the ascending aorta and the aortic arch might become a fast and cost-effective tool for the long-term monitoring of aortic aneurysms in extracranial GCA. Vascular ultrasound also has a role for Takayasu arteritis, thrombosis, Behçet's syndrome, and Raynaud's phenomenon.
Topics: Humans; Rheumatology; Carotid Intima-Media Thickness; Giant Cell Arteritis; Polymyalgia Rheumatica; Temporal Arteries
PubMed: 37419758
DOI: 10.1016/j.berh.2023.101847 -
Reumatismo Mar 2018Polymyalgia rheumatica (PMR) is a chronic, inflammatory disorder of unknown cause, almost exclusively occurring in people aged over 50 and often associated with giant... (Review)
Review
Polymyalgia rheumatica (PMR) is a chronic, inflammatory disorder of unknown cause, almost exclusively occurring in people aged over 50 and often associated with giant cell arteritis. The evidence that PMR occurs almost exclusively in individuals aged over 50 may indicate that age-related immune alterations in genetically predisposed subjects contribute to development of the disease. Several infectious agents have been investigated as possible triggers of PMR even though the results are inconclusive. Activation of the innate and adaptive immune systems has been proved in PMR patients as demonstrated by the activation of dendritic cells and monocytes/macrophages and the altered balance between Th17 and Treg cells. Disturbed B cell distribution and function have been also demonstrated in PMR patients suggesting a pathogenesis more complex than previously imagined. In this review we will discuss the recent findings regarding the pathogenesis of PMR.
Topics: Adaptive Immunity; Aged; B-Lymphocytes; Biomarkers; Cell Differentiation; Evidence-Based Medicine; Giant Cell Arteritis; Humans; Immunity, Innate; Polymyalgia Rheumatica; T-Lymphocytes, Regulatory; Th17 Cells
PubMed: 29589398
DOI: 10.4081/reumatismo.2018.1048