Serum cytokines and steroidal hormones in polymyalgia rheumatica and elderly-onset rheumatoid arthritis.
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BACKGROUND: Polymyalgia rheumatica (PMR) may create some difficulties in the differential diagnosis of elderly-onset rheumatoid arthritis (EORA) and of EORA with PMR-like onset (EORA/PMR). AIM: To investigate possible differences between three groups of patients, with regard to serum levels of inflammatory cytokines and steroidal hormones at baseline and after 1 month of treatment with glucocorticoids (prednisone 7.5-12.5 mg/day). PATIENTS AND METHODS: 14 patients with PMR, 15 with EORA and 14 with EORA/PMR, as well as 15 healthy, matched controls were analysed. Tumour necrosis factor alpha (TNFalpha), interleukin (IL)6, IL1 receptor antagonist (IL1Ra), cortisol, dehydroepiandrosterone sulphate (DHEAS) and 17-hydroxy-progesterone (PRG) were evaluated. RESULTS: Serum levels of both TNFalpha and IL6 were significantly higher in all three groups of patients than in controls (p<0.01). Serum IL6 levels were significantly higher in patients with both PMR and EORA/PMR than in patients with EORA (p<0.05). IL1Ra serum levels were significantly higher in patients with EORA than in controls (p<0.001) and in patients with PMR and EORA/PMR (p<0.05). DHEAS was significantly lower in patients with EORA/PMR than in those with EORA (p<0.05). PRG was significantly higher in all patient groups (p<0.05). After glucocorticoid treatment, serum TNFalpha and IL6 levels significantly decreased in all patient groups; IL1Ra significantly increased in patients with PMR and in those with EORA/PMR; cortisol, DHEAS, and PRG significantly decreased in patients with PMR and in those with EORA/PMR (p<0.05). CONCLUSIONS: Different cytokine and steroidal hormone patterns suggest that patients with PMR and those with EORA/PMR seem to be have a more intensive inflammatory reaction and are more efficient responders to glucocorticoid treatment than patients with EORA. (+info)
Polymyalgia rheumatica and giant cell arteritis--An ophthalmic emergency.
(66/201)
BACKGROUND: The occurrence of giant cell arteritis (GCA) in the setting of polymyalgia rheumatica (PMR) is not uncommon. It is imperative to recognise the symptoms and signs of GCA in this setting as the treatment of PMR with low dose corticosteroids will not protect the patient against the blinding consequences of GCA. OBJECTIVE: This article reports the case of a woman with PMR who developed sudden and irreversible vision loss due to GCA. DISCUSSION: It is important to recognise GCA in patients with PMR before the onset of permanent visual disability. A rising erythrocyte sedimentation rate in such patients may herald the onset of GCA. Other risk factors for GCA include age over 50 years, female gender, symptoms of ischaemia, and temporal artery abnormalities on examination. The latter two features warrant urgent ophthalmic or rheumatological review. (+info)
Polymyalgia rheumatica and giant cell arteritis.
(67/201)
Polymyalgia rheumatica and giant cell arteritis are common, closely related vasculitic conditions that almost exclusively occur in patients older than 50 years. They may be manifestations of the same underlying disease and often coexist. Patients with polymyalgia rheumatica usually present with acute onset of stiffness and pain in the shoulder and pelvic musculature, which may be accompanied by fever, malaise, and weight loss. If untreated, polymyalgia rheumatica may result in significant disability. Giant cell arteritis may manifest as visual loss or diplopia, abnormalities of the temporal artery such as tenderness or decreased pulsation, jaw claudication, and new-onset headaches. Erythrocyte sedimentation rate and temporal artery biopsy help make the diagnosis. Giant cell arteritis requires urgent diagnosis because without treatment it may lead to irreversible blindness. Patients with either condition also may have nonspecific symptoms. Corticosteroids are the mainstay of therapy for both conditions, with higher doses required for treatment of giant cell arteritis. Duration of corticosteroid therapy can be five years or longer before complete clinical remission is achieved. Monitoring for corticosteroid-associated side effects such as osteoporosis and diabetes, as well as for relapses and flare-ups, is key to chronic management. The prognosis for either condition, if treated, is good. (+info)
Repetitive 18-fluorodeoxyglucose positron emission tomography in isolated polymyalgia rheumatica: a prospective study in 35 patients.
(68/201)
OBJECTIVE: To study fluorodeoxyglucose (FDG) deposition in different vascular beds and in the large joints of patients with isolated polymyalgia rheumatica (PMR), and to investigate whether there is a relation between FDG-positron emission tomography (PET) results and risk of relapse. METHODS: All consecutive patients with isolated PMR underwent a FDG-PET scan before treatment with steroids was started and--if logistics allowed--at 3 and 6 months. PET scans were scored at seven different vascular areas and a total vascular score (TVS) was calculated, ranging from 0 to 21. FDG uptake in the shoulders, the hips and the processi spinosi of the vertebrae was scored as 0 (no uptake), 1 (moderate uptake) or 2 (intense uptake). RESULTS: Thirty-five patients entered the study. At diagnosis, vascular FDG uptake was noted in 11 patients (31%), predominantly at the subclavian arteries. Mean TVS was low. FDG uptake in the shoulders was noted in 94% of patients, in the hips in 89% and in the processi spinosi of the vertebrae in 51%. The intensity of FDG uptake in the large vessels or in the shoulders, hips or processi spinosi did not correlate with the risk of relapse. CONCLUSIONS: Only one in three patients has an (moderately) increased vascular FDG uptake, especially in the subclavian arteries. The vast majority has inflammation of shoulders and hips, and half of them have increased FDG-uptake at the processi spinosi. Results of FDG-PET scans in patients with PMR did not correlate with their risk of relapse. (+info)
Glucocorticoids and cardiovascular and cerebrovascular events in polymyalgia rheumatica.
(69/201)
OBJECTIVE: To examine the effect of glucocorticoid use on the risk of various cardiovascular diseases in patients with polymyalgia rheumatica (PMR). METHODS: We assembled a population-based incidence cohort of 364 patients with PMR first diagnosed between January 1, 1970 and December 31, 1999. Inclusion criteria were age > or = 50 years, bilateral aching and morning stiffness involving at least 2 areas (neck, shoulders, hips, or proximal aspects of the thighs), and erythrocyte sedimentation rate (ESR) > or = 40 mm/hour. In patients who fulfilled the first 2 criteria but had a normal ESR, a rapid response to low-dose glucocorticoids served as the third criterion. Patients were followed up until death or December 31, 2004. Cox models with time-dependent covariates were used to examine the association between glucocorticoid exposure and risk of myocardial infarction, heart failure, peripheral vascular disease, and cerebrovascular disease. RESULTS: A total of 364 PMR patients (mean age 73 years, 67% women) were followed for a median of 7.6 years. During the disease course, 310 (85%) patients received glucocorticoids. After adjusting for age, calendar year, and ESR, patients who received glucocorticoids did not have a significantly higher risk for myocardial infarction, heart failure, peripheral vascular disease, or cerebrovascular disease (hazard ratio [95% confidence interval] 0.58 [0.29-1.18], 0.85 [0.45-1.54], 0.58 [0.24-1.40], and 0.65 [0.33-1.26], respectively) compared with those who did not receive glucocorticoids. In fact, a trend for a protective effect was seen. No significant association was observed between cumulative glucocorticoid dose and any of the outcomes (P = 0.39). CONCLUSION: In patients with PMR, treatment with glucocorticoids is not associated with an increased risk of cardiovascular diseases. (+info)
Usefulness of the disease activity scores for polymyalgia rheumatica for predicting glucocorticoid dose changes: a study of 243 scenarios.
(70/201)
OBJECTIVE: To evaluate associations linking glucocorticoid dose changes in patients with polymyalgia rheumatica (PMR) to the PMR activity score (PMR-AS) and its components. METHODS: Nine clinical vignettes of PMR were written by a panel of experts and submitted to 35 rheumatologists, who were asked to assess disease activity using a visual analog scale (VASph) and to determine whether there was a relapse of PMR requiring an increase in the glucocorticoid dose. In 7 vignettes, >80% of the rheumatologists agreed on the diagnosis of relapse justifying the glucocorticoid dose decision. A total of 243 vignette-physician combinations were obtained. Using these vignettes, we evaluated statistical associations linking a decision to increase the glucocorticoid dose to the value of PMR-AS, of its components (VASph, visual analog scale for pain [VASp], C-reactive protein level [CRP], morning stiffness [MST], and elevation of upper limbs [EUL]), or to the difference in these variables between the last 2 visits (dPMR-AS, dVASph, dVASp, dCRP, dMST, and dEUL). RESULTS: The strongest associations with a decision to increase the glucocorticoid dose occurred with dPMR-AS >4.2, dMST >10 minutes, dVASph >1.55, and dCRP >4 mg/dl (99.3% sensitivity, 100% specificity for all 4 variables); MST >or=10 minutes (100% sensitivity, 99.3% specificity); PMR-AS >or=7 (98.1% sensitivity, 94.3% specificity); VASph >or=2.25 (94.2% sensitivity, 83.6% specificity); and CRP level >or=14.5 mg/liter (66.3% sensitivity, 99.3% specificity). CONCLUSION: Despite inter-individual variations in VASph, PMR-AS was a good indicator of disease activity. However, MST, dMST, dVASph, dPMR-AS, and dCRP performed better than PMR-AS. These variables may be useful in tailoring the glucocorticoid dose to the individual needs of each patient. (+info)
The polymyalgia rheumatica activity score in daily use: proposal for a definition of remission.
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OBJECTIVE: To confirm the reliability and applicability of the Polymyalgia Rheumatica Disease Activity Score (PMR-AS), and to establish a threshold for remission. METHODS: First, 78 patients with PMR (50 women/28 men, mean age 65.97 years) were enrolled in a cross-sectional evaluation. The PMR-AS, patient's satisfaction with disease status (PATSAT; range 1-5), erythrocyte sedimentation rate (ESR; first hour), and a visual analog scale of patients' general health assessment (VAS patient global; range 0-100) were recorded. Subsequently, another 39 PMR patients (24 women/15 men, mean age 68.12 years) were followed longitudinally. Relationships between the PMR-AS, PATSAT, ESR, and VAS patient global were analyzed by the Kruskal-Wallis test, Spearman's rank correlation, and kappa statistics. PMR-AS values in patients with a PATSAT score of 1 and a VAS patient global <10 formed the basis to establish a remission threshold. RESULTS: PMR-AS values were significantly related to PATSAT (P < 0.001), VAS patient global (P < 0.001), and ESR (P < 0.01). PATSAT and VAS patient global were reasonably different (kappa = 0.226). The median PMR-AS score in patients with PATSAT score 1 and VAS patient global <10 was 0.7 (range 0-3.3), and the respective 75th percentile was 1.3. To enhance applicability, a range from 0 to 1.5 was proposed to define remission in PMR. The median ESR in these patients was 10 mm/hour (range 3-28), indicating external validity. CONCLUSION: We demonstrated the reliability, validity, and applicability of the PMR-AS in daily routine. Moreover, we proposed a remission threshold (0-1.5) founded on patient-dependent parameters. (+info)
Clinical outcomes, quality of life, and diagnostic uncertainty in the first year of polymyalgia rheumatica.
(72/201)
OBJECTIVE: To evaluate the impact of polymyalgia rheumatica (PMR) on clinical outcomes and quality of life (QOL); the relationship between laboratory measures and clinical outcomes, and changes in QOL; and agreement between rheumatologists in confirming the initial diagnosis. METHODS: We conducted a prospective study of 129 participants in 8 hospitals in England who met a modified version of the Jones and Hazleman criteria and had not started steroid therapy. The main outcome measures were response to steroids after 3 weeks (minimum 50% improvement in proximal pain, morning stiffness <30 minutes, acute-phase response not elevated), relapses, QOL as measured by the Short Form 36 and Health Assessment Questionnaire, and diagnosis reassessment at 1 year. RESULTS: At 3 weeks, 55% of participants failed to meet our definition of a complete response to steroid therapy. Both physical and mental QOL at presentation were substantially lower than general population norms and improved by 12.6 (95% confidence interval [95% CI] 10.8, 14.4) and 11.2 (95% CI 8.5, 13.8) points, respectively, at 1 year. Proximal pain and longer morning stiffness were significantly associated with lower physical QOL during followup, whereas erythrocyte sedimentation rate was most strongly associated with lower mental QOL during followup. There was moderate agreement between clinicians in confirming the PMR diagnosis (kappa coefficients 0.49-0.65). CONCLUSION: PMR is a heterogeneous disease with a major impact on QOL. Ongoing monitoring should include disease activity based on symptoms, emergence of alternative diagnoses, and early referral of atypical and severe cases. (+info)