-
Rheumatology (Oxford, England) Feb 2024To inform an international task force about current evidence on Treat to Target (T2T) strategies in PMR and GCA.
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.
Topics: Humans; Giant Cell Arteritis; Polymyalgia Rheumatica; Glucocorticoids
PubMed: 37672017
DOI: 10.1093/rheumatology/kead471 -
SAGE Open Medical Case Reports 2023A 77-year-old woman had 2 weeks of fever and flu-like symptoms starting several hours after receiving an mRNA booster for SARS-CoV-2 and the influenza vaccine, in...
A 77-year-old woman had 2 weeks of fever and flu-like symptoms starting several hours after receiving an mRNA booster for SARS-CoV-2 and the influenza vaccine, in separate shots. Laboratory tests showed cholangitis. Medical history included -ε4 carrier genotype, mild Alzheimer's disease, participation in a clinical trial of aducanumab, and resolving polymyalgia rheumatica. The patient recovered with at-home supportive care. She had aducanumab-associated amyloid-related imaging abnormalities-edema (ARIA-E) both before and after the acute cholangitis. Two months following the vaccinations polymyalgia rheumatica recurred. This case raises questions about interactions among immune-mediated disease, complications of anti-amyloid monoclonal antibodies, and adverse events following SARS-CoV-2 mRNA vaccination.
PubMed: 37654545
DOI: 10.1177/2050313X231194507 -
Rheumatology (Oxford, England) May 2024To investigate the hypothesis that a history of PMR is associated with a more severe and damaging disease course in newly diagnosed GCA patients.
OBJECTIVES
To investigate the hypothesis that a history of PMR is associated with a more severe and damaging disease course in newly diagnosed GCA patients.
METHODS
This was a retrospective analysis of GCA patients diagnosed between December 2006 and May 2021. We compared vascular ultrasound findings (presence of vasculitis and vascular stenosis) in GCA patients with and without prior PMR.
RESULTS
Forty-nine of 311 GCA patients (15.8%) had prior PMR in a median of 30.6 (IQR 7.1-67.3) months before GCA diagnosis. Patients with prior PMR more often had large vessel vasculitis (LVV) (51.0% vs 25.0%, P < 0.001) and stenosis within the vasculitic segments (18.4% vs 3.1%, P < 0.001) on ultrasound. In multivariable analysis, prior PMR remained significantly associated with LVV (odds ratio 7.65, 95% CI: 2.72, 23.97, P < 0.001). Polymyalgic symptoms at GCA diagnosis in the patients without prior PMR were not associated with a higher prevalence of LVV (P = 0.156).
CONCLUSION
Patients with a diagnosis of PMR before GCA diagnosis had two times more often large vessel involvement and significant more vasculitic stenoses on ultrasound examination than patients without prior PMR. Pre-existing PMR is an independent risk factor for more extensive and advanced ultrasound findings at GCA diagnosis. The contribution of subclinical vasculitis to disease associated damage should be further studied.
Topics: Humans; Giant Cell Arteritis; Female; Male; Retrospective Studies; Polymyalgia Rheumatica; Aged; Ultrasonography; Vasculitis; Middle Aged; Aged, 80 and over; Constriction, Pathologic
PubMed: 37647653
DOI: 10.1093/rheumatology/kead450 -
Autoimmunity Reviews Jan 2024Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common conditions in older adults. Their clinical connection has been recognized over time, with many... (Review)
Review
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common conditions in older adults. Their clinical connection has been recognized over time, with many patients experiencing both conditions separately, simultaneously or in temporal sequence to each other. Early GCA detection is essential to prevent vascular damage, but identifying subclinical GCA in PMR patients remains a challenge and routine screening is not standard practice. Subclinical GCA prevalence in newly diagnosed PMR patients ranges from 23 to 29%, depending on the screening method. Vessel wall imaging and temporal artery biopsy can detect subclinical GCA. Epidemiology and trigger factors show similarities between the two conditions, but PMR is more common than GCA. Genetic and pathogenesis studies reveal shared inflammatory mechanisms involving dendritic cells, pro-inflammatory macrophages, and an IL-6 signature. However, the inflammatory infiltrates differ, with extensive T cell infiltrates seen in GCA while PMR shows an incomplete profile of T cell and macrophage-derived cytokines. Glucocorticoid treatment is effective for both conditions, but the steroid requirements vary. PMR overall mortality might be similar to the general population, while GCA patients with aortic inflammatory aneurysms face increased mortality risk. The GCA-PMR association warrants further research. Considering their kinship, recently the term GCA-PMR Spectrum Disease (GPSD) has been proposed.
Topics: Humans; Aged; Giant Cell Arteritis; Polymyalgia Rheumatica; Glucocorticoids
PubMed: 37625672
DOI: 10.1016/j.autrev.2023.103415 -
Cureus Jul 2023Polymyalgia rheumatica (PMR) is an inflammatory condition that causes joint pain and stiffness. This case report describes an atypical presentation of PMR that was...
Polymyalgia rheumatica (PMR) is an inflammatory condition that causes joint pain and stiffness. This case report describes an atypical presentation of PMR that was initially misdiagnosed as cervical spinal stenosis, leading to surgery before correctly being diagnosed with PMR. Because of an absence of specific diagnostic tests and a presentation of symptoms that often overlap with other conditions, PMR can be difficult to diagnose. This case highlights the importance of clinical evaluation and awareness of PMR's clinical features to prevent unnecessary interventions and ensure appropriate management.
PubMed: 37602112
DOI: 10.7759/cureus.42105 -
Frontiers in Immunology 2023Giant Cell Arteritis (GCA) and Polymyalgia Rheumatica (PMR) are overlapping inflammatory diseases. Antigen-presenting cells (APCs), including monocytes and dendritic...
BACKGROUND
Giant Cell Arteritis (GCA) and Polymyalgia Rheumatica (PMR) are overlapping inflammatory diseases. Antigen-presenting cells (APCs), including monocytes and dendritic cells (DCs), are main contributors to the immunopathology of GCA and PMR. However, little is known about APC phenotypes in the peripheral blood at the time of GCA/PMR diagnosis.
METHODS
APCs among peripheral blood mononuclear cells (PBMCs) of treatment-naive GCA and PMR patients were compared to those in age- and sex-matched healthy controls (HCs) using flow cytometry (n=15 in each group). We identified three monocyte subsets, and three DC subsets: plasmacytoid DCs (pDCs), CD141+ conventional DCs (cDC1) and CD1c+ conventional DCs (cDC2). Each of these subsets was analyzed for expression of pattern recognition receptors (TLR2, TLR4), immune checkpoints (CD86, PDL1, CD40) and activation markers (HLA-DR, CD11c).
RESULTS
t-SNE plots revealed a differential clustering of APCs between GCA/PMR and HCs. Further analyses showed shifts in monocyte subsets and a lower proportion of the small population of cDC1 cells in GCA/PMR, whereas cDC2 proportions correlated negatively with CRP (r=-0.52). Classical monocytes of GCA/PMR patients show reduced expression of TLR2, HLA-DR, CD11c, which was in contrast to non-classical monocytes that showed higher marker expression. Additionally, single cell RNA sequencing in GCA patients identified a number of differentially expressed genes related to inflammation and metabolism in APCs.
CONCLUSION
Circulating non-classical monocytes display an activated phenotype in GCA/PMR patients at diagnosis, whereas classical monocytes show reduced expression of activation markers. Whether these findings reflect APC migration patterns or the effects of long-term inflammation remains to be investigated.
Topics: Humans; Giant Cell Arteritis; Polymyalgia Rheumatica; Leukocytes, Mononuclear; Toll-Like Receptor 2; Dendritic Cells; Inflammation
PubMed: 37600779
DOI: 10.3389/fimmu.2023.1201575 -
Rheumatology (Oxford, England) Feb 2024
Topics: Humans; Polymyalgia Rheumatica; Giant Cell Arteritis; Diagnosis, Differential; Receptors, Interleukin-1
PubMed: 37594741
DOI: 10.1093/rheumatology/kead423 -
Cureus Jul 2023A 68-year-old female with a past medical history significant for tophaceous gout presented with pain and stiffness in her bilateral shoulders and hip joints for about...
A 68-year-old female with a past medical history significant for tophaceous gout presented with pain and stiffness in her bilateral shoulders and hip joints for about two weeks after testing positive for COVID-19. Her laboratory results showed an elevated erythrocyte sedimentation rate (ESR) of 74 mm/h and C-reactive protein (CRP) of 25 mg/L. She showed clinical improvement in her symptoms after steroid therapy and was diagnosed with polymyalgia rheumatica (PMR). Despite prompt treatment with steroids, she continued to have persistent joint pain. Also, she developed new bilateral temporal artery tenderness, headaches, blurry vision, and jaw claudication concerning giant cell arteritis (GCA). She was admitted to the hospital for high-dose pulsed IV methylprednisolone and discharged with a steroid taper along with tocilizumab injections. Her symptoms improved rapidly, and she continued to follow up with rheumatology while continuing low-maintenance doses of prednisone. Although the association between PMR and GCA is well-known, the time it takes to reach disease remission, the rate of relapse, and the length of steroid treatment are variable. There are a few COVID-19-associated cases of PMR and GCA; however, the timeline and pathophysiology of this association remain an area for further investigation.
PubMed: 37588300
DOI: 10.7759/cureus.41951 -
Zeitschrift Fur Rheumatologie May 2024Extracapsular inflammation at entheseal sites in the pelvic girdle as demonstrated by magnetic resonance imaging (MRI) was shown to be useful as an additional tool for...
BACKGROUND
Extracapsular inflammation at entheseal sites in the pelvic girdle as demonstrated by magnetic resonance imaging (MRI) was shown to be useful as an additional tool for diagnosing polymyalgia rheumatica (PMR). However, it is unclear whether MRI needs to be performed with contrast enhancement or whether oedema-sensitive sequences are sufficient.
OBJECTIVE
To evaluate the performance of T2w TIRM (turbo inversion recovery magnitude) imaging compared to fat-saturated contrast-enhanced (ce) T1w at predefined pelvic sites to detect extracapsular inflammation in patients with PMR.
METHODS
A total of 120 pelvic MRIs of patients with pelvic girdle pain, 40 with clinically diagnosed PMR and 80 controls, were retrospectively scored by three blinded radiologists separately evaluating the MRI with and without contrast enhancement at 19 previously defined pelvic structures. The intra- and interrater reliability and the diagnostic performance of both techniques were statistically analysed and evaluated.
RESULTS
The detection of inflammatory MRI signals correlated moderately between both techniques (Cohen's κ 0.583). With ceT1w imaging 20.7% more sites were detected as inflamed compared to T2w TIRM in PMR patients. Inter- and intrareader reliability was superior with ceT1w imaging. If the inflammatory signal was detected at three sites bilaterally including the origin of the rectus femoris muscle or adductor longus muscle, the sensitivity and specificity was 100% and 97.1% by ceT1w imaging vs. 80.8% and 93.3% by T2w TIRM, respectively.
CONCLUSION
Contrast enhancement is superior to oedema-sensitive MRI in the detection of extracapsular inflammation in PMR. However, using T2w TIRM also detects many but not all PMR cases.
Topics: Humans; Polymyalgia Rheumatica; Magnetic Resonance Imaging; Female; Sensitivity and Specificity; Male; Aged; Contrast Media; Reproducibility of Results; Image Enhancement; Middle Aged; Aged, 80 and over
PubMed: 37566119
DOI: 10.1007/s00393-023-01394-7 -
Cureus Jul 2023Zoledronic acid is a bisphosphonate commonly used to treat various conditions involving bone loss. While it is generally well-tolerated, the occurrence of severe...
Zoledronic acid is a bisphosphonate commonly used to treat various conditions involving bone loss. While it is generally well-tolerated, the occurrence of severe inflammatory reactions is rare. We present the case of an 82-year-old female who developed a severe immune reaction, including weakness and tenderness in her upper and lower extremities, following a single dose of zoledronic acid infusion for the treatment of osteoporosis. The onset of symptoms occurred one week after the infusion and persisted, progressively worsening over time, leading to functional impairment and the need for a walker for ambulation. Laboratory studies revealed an elevated erythrocyte sedimentation rate while other autoimmune markers were within normal limits. Differential diagnosis included an adverse reaction to zoledronic acid or underlying polymyalgia rheumatica. The patient showed significant improvement with a prednisone taper, suggesting an immune-mediated response. This case highlights the importance of considering severe immune reactions as a potential side effect of zoledronic acid and emphasizes the need for further research to better understand the underlying mechanisms and optimize patient management.
PubMed: 37551226
DOI: 10.7759/cureus.41524