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Seminars in Arthritis and Rheumatism Jun 2020We investigated the effectiveness of tocilizumab (an anti-interleukin-6 receptor antibody) in patients with polymyalgia rheumatica (PMR).
OBJECTIVE
We investigated the effectiveness of tocilizumab (an anti-interleukin-6 receptor antibody) in patients with polymyalgia rheumatica (PMR).
METHODS
We performed a systematic literature review from the inception dates until August 7, 2019 for articles reporting tocilizumab administration to treat isolated PMR.
RESULTS
We identified 59 patients with isolated PMR treated with tocilizumab. All studies used intravenously administered tocilizumab at a dose of 8 mg/kg monthly. Tocilizumab monotherapy was administered to 24 and combination therapy (tocilizumab + glucocorticoid) to 35 patients. Tocilizumab monotherapy achieved low disease activity scores in only 17% of patients at week 4 and in only 71% patients even at week 12. Compared to glucocorticoid monotherapy, the reduction in the cumulative glucocorticoid dose was between 58% and 70% using a combination of tocilizumab and glucocorticoids, and 33-100% of the patients eventually showed glucocorticoid-free remission. All relapses occurred in patients administered tocilizumab monotherapy. No new safety event was reported.
CONCLUSION
Tocilizumab is effective in cases of isolated PMR, particularly in combination with glucocorticoids. In addition to its glucocorticoid-sparing effect, it achieves glucocorticoid-free remission and reduces relapse rates. Tocilizumab monotherapy is not recommended.
Topics: Administration, Intravenous; Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Drug Administration Schedule; Drug Therapy, Combination; Female; Glucocorticoids; Humans; Male; Middle Aged; Polymyalgia Rheumatica; Receptors, Interleukin-6; Secondary Prevention
PubMed: 32107035
DOI: 10.1016/j.semarthrit.2019.12.005 -
Journal of Clinical Rheumatology :... Mar 2020Corticosteroids have long been used to effectively treat rheumatic disorders, but adverse effects associated with extended-duration regimens generate disagreement among...
BACKGROUND/OBJECTIVE
Corticosteroids have long been used to effectively treat rheumatic disorders, but adverse effects associated with extended-duration regimens generate disagreement among clinicians regarding optimal tapering strategies. The objective of this systematic review was to assess clinical outcomes of differing tapering regimens after corticosteroid monotherapy in adults with rheumatic disorders.
METHODS
A systematic review of Medline/PubMed, Embase, Cochrane, International Pharmaceutical Abstracts, Web of Science, Scopus, Global Index Medicus, American College of Rheumatology, gray literature, and reference lists up to June 27, 2018, was conducted by 2 authors. Randomized controlled trials, case-control studies, and prospective observational studies comparing at least 2 tapering strategies of medium- to high-dose (>7.5 mg but ≤100 mg oral prednisone equivalent daily), extended-duration (≥10 days) corticosteroids were included if they reported at least 1 efficacy and 1 adverse effect parameter.
RESULTS
Two studies met criteria for the review, which included 62 patients. One study examined a prednisolone versus a modified release prednisone taper for giant cell arteritis and suggested 80% (n = 4) and 85.7% (n = 6) remission rates, respectively, at 26 weeks. The other study examined a methylprednisolone versus a prednisone taper for polymyalgia rheumatica and reported 100% and 89% remission rates, respectively, at 26 weeks. Adverse effects reported between the 2 studies included sleep, hyperglycemia, infection, and fractures. However, the studies were not powered to detect differences in these outcomes.
CONCLUSIONS
There is no high-level evidence to guide tapering until discontinuation after extended courses of medium- to high-dose treatment regimens, as current guidelines rely heavily on expert opinion and small case series with a trial-and-error approach. This review supports the need for additional research to shift tapering recommendations to a more evidence-based practice.
Topics: Adrenal Cortex Hormones; Adult; Glucocorticoids; Humans; Methylprednisolone; Observational Studies as Topic; Polymyalgia Rheumatica; Prednisone
PubMed: 32073513
DOI: 10.1097/RHU.0000000000000917 -
Journal of Clinical Rheumatology :... Jan 2021Giant cell arteritis (GCA) is a systemic vasculitis that commonly co-occurs with polymyalgia rheumatica (PMR) in elderly patients. Pericardial disease is an unusual...
BACKGROUND
Giant cell arteritis (GCA) is a systemic vasculitis that commonly co-occurs with polymyalgia rheumatica (PMR) in elderly patients. Pericardial disease is an unusual manifestation of these inflammatory conditions, which has been reported only in case reports and small observational studies. However, no extensive research has been performed to study the demographics and clinical history of GCA or PMR patients with concomitant pericardial features. As a result, the medical evidence to help guide the physicians when evaluating such individuals is limited.
OBJECTIVE
To perform a systematic review of the medical literature in order to summarize the epidemiological and clinicopathological aspects of this unique association.
METHODS
We conducted an extensive search of PubMed, Cochrane Library, Ovid, Google Scholar, and gray literature to identify all the cases of GCA and PMR with pericardial involvement. The demographics, clinical features, and outcomes of the final cohort were reviewed and analyzed.
RESULTS
The analysis comprised 52 clinical cases (51 identified from 46 articles and 1 from the residents' clinic). These included 44 patients with GCA and 8 with PMR. The mean age at presentation was 69.5 years, with only 46% of patients older than 70 years. The most common abnormality was pericardial effusion (85%), and in 37%, the pericardial event was the initial disease manifestation. Although a significant proportion of the patients were symptomatic (69%), the classic cranial symptoms were present in only 40%. Overall, the outcome was good even in the presence of large-vessel disease, which is usually a poor prognostic factor in classic GCA. On group analysis, patients with PMR were more likely to develop cardiac tamponade (37.5%; odds ratio, 25.8; confidence interval, 2.2-297.5; p = 0.01), whereas those with GCA were more likely to have large-vessel vasculitis (43%; odds ratio, 5.18; confidence interval, 0.58-252.1; p = 0.04).
CONCLUSIONS
This study illustrates that patients with pericardial involvement represent a clinical phenotype of GCA (and possibly PMR), which is quite different from the cranial or large-vessel forms. These patients have a better prognosis likely due to younger age and presence of more overt symptoms resulting in early diagnosis.
Topics: Giant Cell Arteritis; Humans; Pericardial Effusion; Pericardium; Polymyalgia Rheumatica; Prognosis
PubMed: 31483352
DOI: 10.1097/RHU.0000000000001140 -
Acta Reumatologica Portuguesa 2019Ultrasound (US) is a relatively cheap, easily available and reliable method to improve the care of rheumatic patients. However, its use in rheumatology practice is very...
INTRODUCTION
Ultrasound (US) is a relatively cheap, easily available and reliable method to improve the care of rheumatic patients. However, its use in rheumatology practice is very heterogeneous and needs to be standardized.
OBJECTIVES
To develop recommendations for the use of US in rheumatic diseases endorsed by the Portuguese Society of Rheumatology.
METHODS
A systematic literature review of the available recommendations on the use of ultrasound in rheumatic diseases was performed and presented in a Portuguese Society of Rheumatology meeting to a subgroup of rheumatologists and rheumatology trainees with special interest in the subject. The most important topics to be addressed were selected and assigned to subgroups for literature review and draft recommendations. Following an iterative process of consensus, the final recommendations were developed, and their level of agreement voted anonymously online. A recommendation was approved when the average level of agreement was ≥ 7.5 in a 10-point Likert scale.
RESULTS
Fourteen recommendations were produced regarding nine rheumatology topics: rheumatoid arthritis, spondyloarthritis, connective tissue diseases, polymyalgia rheumatica, vasculitis, crystal-deposition diseases, soft tissue rheumatism, osteoarthritis and ultrasound-guided procedures.
CONCLUSION
We developed an up-to-date guidance in the form of recommendations for the use of US in nine different areas of rheumatology. As ultrasound is an important imaging modality with increasing use in the rheumatology setting, and there are frequent technological advances in the ultrasound machines and probes, in parallel with continuous associated research, these recommendations should be regularly updated.
Topics: Arthritis, Rheumatoid; Humans; Joint Diseases; Portugal; Rheumatic Diseases; Rheumatology; Ultrasonography
PubMed: 31249273
DOI: No ID Found -
RMD Open 2019To assess whether the polymyalgia rheumatica (PMR)-like syndrome reported as an immune related adverse event (irAE) from checkpoint inhibitor therapy is consistent with... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To assess whether the polymyalgia rheumatica (PMR)-like syndrome reported as an immune related adverse event (irAE) from checkpoint inhibitor therapy is consistent with the 2012 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) provisional criteria for PMR.
METHODS
The cases were derived from two sources. Group 1 represents reported cases from three contributing centres. Group 2 was derived from a systematic review of the literature searching for all cases reported as PMR or PMR-like illness associated with checkpoint inhibitor therapy. Cases were assessed for the quality of reporting and then analysed to determine whether they fulfilled the 2012 EULAR/ACR provisional criteria for PMR.
RESULTS
A total of 49 patients were included for analysis. Among the entire group, 37 (75%) were designated 'complete' indicating that they had sufficient data to reliably apply the 2012 EULAR/ACR criteria. 28 (75%) cases fulfilled complete criteria for PMR. A number of cases also demonstrated some clinical features unusual for idiopathic PMR.
CONCLUSION
This study suggests a high proportion of reported cases of checkpoint inhibitor-related PMR fulfil preliminary criteria for PMR, yet in one quarter clinical details were incomplete making verification problematic. Furthermore, in the absence of a gold standard for the diagnosis of PMR, the relationship of checkpoint inhibitor-related PMR to the idiopathic form remains unclear.
Topics: Antirheumatic Agents; Biomarkers; Humans; Molecular Targeted Therapy; Polymyalgia Rheumatica; Treatment Outcome
PubMed: 31168414
DOI: 10.1136/rmdopen-2019-000906 -
The Journal of Rheumatology Oct 2019To report the progress of the Outcome Measures in Rheumatology (OMERACT) Polymyalgia Rheumatica (PMR) Working Group in selecting candidate instruments for a core outcome...
OBJECTIVE
To report the progress of the Outcome Measures in Rheumatology (OMERACT) Polymyalgia Rheumatica (PMR) Working Group in selecting candidate instruments for a core outcome measurement set.
METHODS
A systematic literature review identified outcomes measured and instruments used in PMR studies, and a respondent survey and raw data analysis assessed their domain match and feasibility.
RESULTS
Candidate instruments were identified for pain [visual analog scale/numerical rating scale (VAS/NRS)], stiffness (VAS/NRS and duration), and physical function (Health Assessment Questionnaire-Disability Index/modified Health Assessment Questionnaire). Domain match and feasibility assessments were favorable; however, validation in PMR was lacking.
CONCLUSION
Further assessment of candidate instruments is required prior to recommending a PMR core outcome measurement set.
Topics: Adult; Aged; Aged, 80 and over; Blood Sedimentation; C-Reactive Protein; Feasibility Studies; Female; Health Surveys; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Pain; Pain Measurement; Polymyalgia Rheumatica; Public Opinion; Visual Analog Scale
PubMed: 30709960
DOI: 10.3899/jrheum.181050 -
Arthritis Research & Therapy Nov 2018Comorbidities are known to exist in many rheumatological conditions. Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition affecting older...
BACKGROUND AND AIM
Comorbidities are known to exist in many rheumatological conditions. Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition affecting older people which, prior to effective treatment, causes severe disability. Our understanding of associated comorbidities in PMR is based only on case reports or series and small cohort studies. The objective of this study is to review systematically the existing literature on the comorbidities associated with PMR.
METHODS
MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched for original observational research from inception to November 2016. Papers containing the words 'Polymyalgia Rheumatica' OR 'Giant Cell Arteritis' OR the terms 'PMR' OR 'GCA' were included. Article titles were reviewed based on pre-defined criteria by two reviewers. Following selection for inclusion, studies were quality assessed using the Newcastle-Ottawa tool and data were extracted.
RESULTS
A total of 17,329 papers were reviewed and 41 were incorporated in this review, including three published after the search took place. Wide variations were found in study design, comorbidities reported and populations studied. Positive associations were found between PMR diagnosis and stroke, cardiovascular disease, peripheral arterial disease, diverticular disease and hypothyroidism. Two studies reported a positive association between PMR and overall malignancy rate. Seven studies reported an association between PMR and specific types of cancer, such as leukaemia, lymphoma, myeloproliferative disease and specified solid tumours, although nine studies found either no or negative association between cancer and PMR.
CONCLUSION
Quantification of the prevalence of comorbidities in PMR is important to accurately plan service provision and enable identification of cases of PMR which may be more difficult to treat. This review highlights that research into comorbidities in PMR is, overall, methodologically inadequate and does not comprehensively cover all comorbidities. Future studies should consider a range of comorbidities in patients with a validated diagnosis of PMR in representative populations.
Topics: Age Factors; Comorbidity; Cross-Sectional Studies; Giant Cell Arteritis; Humans; Neoplasms; Polymyalgia Rheumatica; Prospective Studies; Retrospective Studies; Risk Factors
PubMed: 30458857
DOI: 10.1186/s13075-018-1757-y -
Reumatismo Mar 2018Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disease affecting older people. The current mainstay of treatment is long-term oral glucocorticoid... (Review)
Review
Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disease affecting older people. The current mainstay of treatment is long-term oral glucocorticoid therapy. Management of these patients in clinical practice is often complicated by the presence of comorbidity. Comorbidity might be due to shared risk factors such as age, sex, or genetic background; to the presence of the disease itself; or to adverse effects of glucocorticoid therapy. Cardiovascular disease, osteoporosis/fracture, metabolic and ocular comorbidity are of particular interest to clinicians because of their relationship to glucocorticoid therapy and the relevance to clinical treatment decisions regarding glucocorticoid tapering. Patients at high risk of exacerbation of comorbidity by glucocorticoid therapy may be considered for adjunctive steroid-sparing therapies and thus may need specialist management. From a public health perspective, with the ageing population the prevalence of PMR is predicted to increase; accurate data on comorbidity will be needed for planning and delivery of healthcare services.
Topics: Aged; Cardiovascular Diseases; Comorbidity; Eye Diseases; Glucocorticoids; Humans; Metabolic Diseases; Neoplasms; Osteoporosis; Paraneoplastic Syndromes; Polymyalgia Rheumatica; Prevalence; Risk Factors; United Kingdom
PubMed: 29589401
DOI: 10.4081/reumatismo.2018.1039 -
Reumatismo Mar 2018The aim of this study was to systematically consider the evidence for polymyalgia rheumatica (PMR) as a paraneoplastic disease. A systematic review of Medline and Embase... (Review)
Review
The aim of this study was to systematically consider the evidence for polymyalgia rheumatica (PMR) as a paraneoplastic disease. A systematic review of Medline and Embase was conducted from their inception to February 2017. Risk of bias was assessed using the Newcastle-Ottawa tool. Data were extracted regarding the PMR-cancer association, the types of cancer associated with PMR and the presentation of PMR patients subsequently diagnosed with cancer. Twenty-three full text articles were reviewed from the 1174 unique references identified in the search. Nine articles were included in the final review. There was some evidence of an association between PMR and cancer in the short-term (first 6 to 12 months after diagnosis), but no evidence of an association after this time. Limited evidence suggests that lymphoma, prostate and haematological cancers may be those cancers more commonly diagnosed in those with PMR. There was little evidence to suggest what presenting features may be associated with the development of cancer. There is little evidence of PMR as a true paraneoplastic disease. However, there is reason to be cautious when making the diagnosis of PMR. Clinicians should be aware of this potential association both prior to making a diagnosis and throughout the course of the condition.
Topics: Aged; Diagnosis, Differential; Evidence-Based Medicine; Humans; Paraneoplastic Syndromes; Polymyalgia Rheumatica; Practice Guidelines as Topic; Quality of Life; Risk Assessment; Risk Factors; Severity of Illness Index
PubMed: 29589400
DOI: 10.4081/reumatismo.2018.1031 -
RMD Open 2018Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are almost always treated with glucocorticoids (GCs), but long-term GC use is associated with diabetes...
BACKGROUND
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are almost always treated with glucocorticoids (GCs), but long-term GC use is associated with diabetes mellitus (DM). The absolute incidence of this complication in this patient group remains unclear.
OBJECTIVE
To quantify the absolute risk of GC-induced DM in PMR and GCA from published literature.
METHODS
We identified literature from inception to February 2017 reporting diabetes following exposure to oral GC in patients with PMR and/or GCA without pre-existing diabetes. A random-effects meta-analysis was performed to summarise the findings.
RESULTS
25 eligible publications were identified. In studies of patients with GCA, mean cumulative GC dose was almost 1.5 times higher than in studies of PMR (8.2 g vs 5.6 g), with slightly longer treatment duration and longer duration of follow-up (6.4 years vs 4.4 years). The incidence proportion (cumulative incidence) of patients who developed new-onset DM was 6% (95% CI 3% to 9%) for PMR and 13% (95% CI 9% to 17%) for GCA. Based on UK data on incidence rate of DM in the general population, the expected background incidence rate of DM over 4.4 years in patients with PMR and 6.4 years in patients with GCA (follow-up duration) would be 4.8% and 7.0%, respectively. Heterogeneity between studies was high (I=79.1%), as there were differences in study designs, patient population, geographical locations and treatment. Little information on predictors of DM was found.
CONCLUSION
Our meta-analysis produced plausible estimates of DM incidence in patients with PMR and GCA, but there is insufficient published data to allow precise quantification of DM risk.
PubMed: 29531778
DOI: 10.1136/rmdopen-2017-000521