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An update on polymyalgia rheumatica
Ingrid E Lundberg1, Ankita Sharma2, Carl Turesson2,3
1Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden.
Abstract:
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease affecting people older than 50 years and is 2-3 times more common in women. The most common symptoms are pain and morning stiffness in the shoulder and pelvic girdle and the onset may be acute or develop over a few days to weeks. General symptoms such as fatigue, fever and weight loss may occur, likely driven by systemic IL-6 signalling. The pathology includes synovial and periarticular inflammation and muscular vasculopathy. A new observation is that PMR may appear as a side effect of cancer treatment with checkpoint inhibitors. The diagnosis of PMR relies mainly on symptoms and signs combined with laboratory markers of inflammation. Imaging modalities including ultrasound, magnetic resonance imaging and positron emission tomography with computed tomography are promising new tools in the investigation of suspected PMR. However, they are still limited by availability, high cost and unclear performance in the diagnostic workup. Glucocorticoid (GC) therapy is effective in PMR, with most patients responding promptly to 15-25 mg prednisolone per day. There are challenges in the management of patients with PMR as relapses do occur and patients with PMR may need to stay on GC for extended periods. This is associated with high rates of GC-related comorbidities, such as diabetes and osteoporosis, and there are limited data on the use of disease-modifying antirheumatic drugs and biologics as GC sparing agents. Finally, PMR is associated with giant cell arteritis that may complicate the disease course and require more intense and prolonged treatment.
Insights
Polymyalgia rheumatica (PMR) is a common inflammatory condition in older adults, primarily causing pain and stiffness. While glucocorticoids are effective, long-term use presents challenges due to side effects and potential relapses.
Area of Science:
- Rheumatology
- Immunology
- Internal Medicine
Background:
- Polymyalgia rheumatica (PMR) is the most prevalent inflammatory rheumatic disease in individuals over 50, predominantly affecting women.
- Key symptoms include shoulder and pelvic girdle pain and morning stiffness, with potential for acute onset or gradual development.
- Systemic symptoms like fatigue, fever, and weight loss are observed, possibly linked to interleukin-6 (IL-6) signaling.
Purpose of the Study:
- To provide a comprehensive overview of polymyalgia rheumatica (PMR), encompassing its epidemiology, clinical presentation, and underlying pathology.
- To discuss current diagnostic approaches, including clinical evaluation, laboratory markers, and emerging imaging techniques.
- To review the therapeutic landscape of PMR, focusing on glucocorticoid treatment, its challenges, and potential adjunctive therapies.
Main Methods:
- Literature review of epidemiological, clinical, and pathological studies on PMR.
- Analysis of diagnostic criteria and the role of inflammatory markers and advanced imaging.
- Evaluation of treatment strategies, including glucocorticoid efficacy, management of relapses, and exploration of steroid-sparing agents.
Main Results:
- PMR is characterized by synovial and periarticular inflammation and muscular vasculopathy.
- Diagnosis relies on clinical presentation, inflammatory markers, with imaging modalities showing promise but facing limitations.
- Glucocorticoid therapy is effective but associated with significant long-term side effects and frequent relapses.
Conclusions:
- PMR management requires careful consideration of glucocorticoid-related comorbidities and the potential for disease relapses.
- Further research is needed on disease-modifying antirheumatic drugs and biologics as steroid-sparing options.
- PMR is associated with giant cell arteritis, necessitating vigilant monitoring and potentially more intensive treatment.
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