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Relapse in a population based cohort of patients with polymyalgia rheumatica
Hilal Maradit Kremers1, Megan S Reinalda, Cynthia S Crowson
1Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905, USA.
Objective:
To determine the incidence and the clinical, laboratory, and treatment related predictors of relapse in polymyalgia rheumatica (PMR).
Methods:
Using the population based resources of the Rochester Epidemiology Project, we assembled an incidence cohort of subjects with PMR first diagnosed between January 1, 1970, and December 31, 1999. For inclusion, subjects were required to fulfill 3 criteria: (1) age > or = 50 years; (2) bilateral aching and morning stiffness in neck, shoulders, or hip girdle regions; and (3) erythrocyte sedimentation rate (ESR) > or = 40 mm/h. In subjects who fulfilled the first 2 criteria but had a normal ESR, a rapid response to low dose corticosteroids (CS) served as the third criterion. Patients were followed until permanent remission, migration, or a maximum of 5 years after their incidence date. Relapse was defined as an exacerbation of PMR symptoms requiring an adjustment of CS dose (> or = 5 mg) occurring at least 30 days after the incidence date. Time to relapse was modeled using the Kaplan-Meier method. CS treatment patterns were modeled using linear and nonlinear models. Cox regression models were used to evaluate predictors of time to first and subsequent relapses.
Results:
The study population included 364 patients with a mean age of 73.4 years and 244 (67%) were women. Among the 284 patients treated with CS, a higher initial CS dose and faster CS tapering rate were significant predictors of future relapses, after adjusting for age, sex, ESR, giant cell arteritis at PMR diagnosis, and the intensity of rheumatologist care. Every 5 mg/day increase in initial CS dose was associated with a 7% increase in the risk of relapse [hazard ratio (HR) 1.07, 95% CI 1.02, 1.13]. The hazard of having a relapse was 4-fold higher when the CS tapering rate was fast (HR 4.27, 95% CI 2.84, 6.44), and 2-fold higher when the CS tapering rate was medium (HR 2.19, 95% CI 1.54, 3.11) compared to slow tapering.
Conclusion:
Higher initial CS doses and faster tapering are significant predictors of future relapses. Our results suggest that efforts should be made to minimize initial CS dose and taper CS slowly in order to avoid disease relapses.
Insights
Higher initial corticosteroid (CS) doses and faster CS tapering increase relapse risk in polymyalgia rheumatica (PMR). Minimizing initial CS dose and tapering slowly can help avoid PMR relapses.
Area of Science:
- Rheumatology
- Epidemiology
- Clinical Medicine
Background:
- Polymyalgia rheumatica (PMR) is an inflammatory condition affecting individuals over 50.
- Understanding relapse predictors is crucial for optimizing patient management and treatment strategies.
- Corticosteroids (CS) are the primary treatment, but relapse rates remain a concern.
Purpose of the Study:
- To identify clinical, laboratory, and treatment-related predictors of relapse in polymyalgia rheumatica (PMR).
- To analyze the relationship between corticosteroid (CS) dosing and tapering strategies and PMR relapse risk.
Main Methods:
- A population-based cohort of 364 PMR patients diagnosed between 1970-1999 was assembled.
- Inclusion criteria included age (>=50), characteristic symptoms, and elevated ESR or rapid CS response.
- Time to relapse was modeled using Kaplan-Meier, and predictors were analyzed with Cox regression.
Main Results:
- Higher initial corticosteroid (CS) doses significantly predicted future relapses (HR 1.07 per 5 mg/day increase).
- Faster CS tapering rates were strongly associated with increased relapse risk (HR 4.27 for fast, HR 2.19 for medium tapering).
- These findings remained significant after adjusting for age, sex, ESR, and other clinical factors.
Conclusions:
- Elevated initial corticosteroid (CS) dosage and rapid CS tapering are significant predictors of relapse in polymyalgia rheumatica (PMR).
- Strategies to minimize initial CS dose and implement slow CS tapering should be considered to reduce disease relapses.
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