Challenges in the diagnosis of polymyalgia rheumatica and related giant cell arteritis.

INTRODUCTION: Polymyalgia rheumatica (PMR) has emerged as a relatively common condition in Western countries. Although the diagnosis is relatively straightforward in people over 50 years of age who complain of sudden onset of pain and stiffness in the shoulder and hip girdles along with elevation of biomarkers of inflammation, manifestations of polymyalgia can also occur in the context of different conditions. For this reason, a complete history and examination is required, including looking for symptoms and signs suggestive of giant cell arteritis (GCA). AREAS COVERED: The review describes when and how to identify PMR, as well as when to suspect the presence of associated GCA or multiple conditions mimicking PMR. EXPERT OPINION: PMR does not have a specific diagnostic test. For this reason, a thorough clinical history searching for clinical data of GCA is needed. Moreover, the possibility of other diseases mimicking PMR should be considered, particularly when atypical presentation or unusual clinical data are present.

Development and validation of a new disease activity index as a numerical sum of four variables in patients with early arthritis.

OBJECTIVE: To describe the development and validation of a disease activity index in early arthritis that can be easily applied in daily practice and clinical research. METHODS: The Hospital Universitario La Princesa Index (HUPI) was developed after analysis of data from an early arthritis cohort (202 patients with 756 visits). It is the sum of 4 variables (graded 0-3): tender joint count, swollen joint count, patient global assessment, and acute-phase reactants (erythrocyte sedimentation rate [ESR] and/or C-reactive protein [CRP] level, depending on availability at the moment of evaluation). The score for each variable was based on its quartile distribution in the cohort. The HUPI was validated using the following properties: feasibility, internal consistency (Cronbach's alpha), convergent validity (Pearson's r coefficients with other activity measures), criterion validity (area under the receiver operating characteristic curve [AUC ROC] to detect minimal disease activity [MDA]), and sensitivity to change (AUC ROC) to detect change with the physician's and patient's assessment of disease activity. RESULTS: Internal consistency is reasonable (α = 0.63). The HUPI correlates well with activity measures such as the Disease Activity Score in 28 joints (DAS28; r = 0.89) and the Simplified Disease Activity Index (SDAI; r = 0.70), and correlates slightly worse with the functional index of the Health Assessment Questionnaire (r = 0.69). It discriminates MDA correctly (AUC 0.95), and its sensitivity to change is slightly superior (AUC 0.902) to that of the DAS28-ESR (AUC 0.864), the DAS28-CRP (AUC 0.889), and the SDAI (AUC 0.791). CONCLUSION: The HUPI has face validity, is easy to calculate, is sensitive, and is a valid composite index for the assessment of disease activity in patients with early arthritis, both in clinical research and in routine care.

Risk of malignancies in patients with rheumatoid arthritis treated with biologic therapy: a meta-analysis.

CONTEXT: Concerns exist regarding the potential development of malignancies in patients with rheumatoid arthritis (RA) who are receiving biologic response modifiers (BRMs). OBJECTIVE: To assess the risk of malignancy in patients with RA enrolled in randomized controlled trials (RCTs) of BRMs. DATA SOURCES: Electronic databases, conference proceedings, and websites of regulatory agencies were searched for RCTs evaluating abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, and tocilizumab in RA from inception through July 9, 2012. STUDY SELECTION: Independent selection of studies included RCTs that compared the safety of any BRMs used in RA patients with placebo and/or any traditional disease-modifying antirheumatic drugs with a minimum of 24 weeks of follow-up. DATA EXTRACTION: Independent reviewers selected studies and extracted data on quality and outcomes. Pooled estimates and 95% confidence intervals were calculated for each BRM. RESULTS: Sixty-three RCTs with 29,423 patients were analyzed. No statistically significant increased risk of developing malignancy was observed. Of the 29,423 patients, 211 developed a malignancy during the trial (118 solid tumors, 48 skin cancers, 14 lymphomas, 5 hematologic nonlymphomas, and 26 not specified). The incidence rate for any malignancy during the first year of therapy was very low in the BRM plus methotrexate group (0.77%; 95% CI, 0.65%-0.92%), the BRM monotherapy group (0.64%; 95% CI, 0.42%-0.95%), and the controls (0.66%; 95% CI, 0.52%-0.84%). Anakinra plus methotrexate showed lower odds compared with methotrexate alone (Peto odds ratio, 0.11; 95% CI, 0.03-0.45). No statistically significant risk was observed for specific cancer sites, although the Peto odds ratio for lymphoma was 2.1 (95% CI, 0.55-8.4) in patients receiving tumor necrosis factor inhibitors compared with controls. CONCLUSION: The use of BRMs among patients with RA included in RCTs of at least 6 months' duration was not significantly associated with an increased risk of malignancy compared with other disease-modifying antirheumatic drugs or with placebo.

Influencia del género en la respuesta al tratamiento en una cohorte de pacientes con artritis reumatoide precoz del área 2 de la Comunidad de Madrid / Influence of gender on treatment response in a cohort of patients with early rheumatoid arthritis in the area 2 of Madrid

Objetivo Valorar las diferencias de respuesta al tratamiento mediante DAS28 calculado mediante velocidad de sedimentación globular (VSG) y proteína C reactiva teniendo en cuenta el género del paciente y analizar el comportamiento individual de cada uno de sus componentes en una cohorte de pacientes de artritis precoz en el área 2 de la Comunidad de Madrid. Pacientes y métodos Se estudiaron un total de 134 pacientes (77,6% mujeres) que cumplían criterios del Colegio Americano de Reumatología para el diagnóstico de artritis reumatoide del registro de artritis precoz del Hospital de La Princesa. En dicho registro se realizaron 4 visitas protocolizadas en las que se recogen de forma sistemática los datos necesarios para calcular el DAS28 con VSG y proteína C reactiva, así como el tratamiento prescrito a los pacientes. Se analizaron las diferencias por género en la respuesta al tratamiento mediante ambos índices compuestos, así como de las variables que los componen y la valoración de la enfermedad por el médico. Resultados Las mujeres presentaron mayor actividad de la enfermedad y discapacidad al inicio del seguimiento. A pesar de que estas recibieron un tratamiento más intenso, su valor promedio de DAS28 no llegó a igualarse con el de los hombres a lo largo del seguimiento. Por el contrario, la valoración de la enfermedad por parte del paciente y del médico sí llegó a igualarse. Al analizar los componentes del DAS28 por separado, se observó que esta discordancia era debida principalmente a las variables VSG y recuento de articulaciones dolorosas. Conclusiones La VSG y el recuento de articulaciones dolorosas causan un sesgo en la evaluación de la actividad de la artritis reumatoide con el DAS28 que puede afectar a la evaluación de la respuesta al tratamiento (AU)

Objective To evaluate the differences between the responses to treatment using DAS28 based on erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in male and female patients. We then analyzed the individual behaviour of each component in a cohort of early arthritis patients in zone 2 of Madrid. Patients and methods We studied a total of 134 patients (77.6% women) who met the American College of Rheumatology (ACR) criteria for the diagnosis of rheumatoid arthritis (RA) belonging to an early arthritis register of the Hospital de La Princesa. We performed 4 visits following a standardized protocol which included necessary variables to calculate the DAS28 with ESR and CRP as well as determining the treatment received by the patients. We analyzed the differences in responses to treatment in males and females using both indexes, as well as their component and the assessment of the disease by the physician. Results Women had higher disease activity and disability at baseline. Although they received more intensive treatment, their average value of DAS28 remained significantly higher compared to men during the follow-up. By contrast, the global disease assessment evaluated by the patient and by the physician remained similar in both gender. When we analyze the DAS28 components separately, it was observed that this discrepancy was due mainly to the tender joints count and the ESR. Conclusions Women with early RA have higher DAS28ESR scores as a result of higher tender joint counts and ESR. This may represent bias when assessing the response to treatment using the DAS28ESR (AU)

[Influence of gender on treatment response in a cohort of patients with early rheumatoid arthritis in the area 2 of Madrid]. / Influencia del género en la respuesta al tratamiento en una cohorte de pacientes con artritis reumatoide precoz del área 2 de la Comunidad de Madrid.

OBJECTIVE: To evaluate the differences between the responses to treatment using DAS28 based on erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in male and female patients. We then analyzed the individual behaviour of each component in a cohort of early arthritis patients in zone 2 of Madrid. PATIENTS AND METHODS: We studied a total of 134 patients (77.6% women) who met the American College of Rheumatology (ACR) criteria for the diagnosis of rheumatoid arthritis (RA) belonging to an early arthritis register of the Hospital de La Princesa. We performed 4 visits following a standardized protocol which included necessary variables to calculate the DAS28 with ESR and CRP as well as determining the treatment received by the patients. We analyzed the differences in responses to treatment in males and females using both indexes, as well as their component and the assessment of the disease by the physician. RESULTS: Women had higher disease activity and disability at baseline. Although they received more intensive treatment, their average value of DAS28 remained significantly higher compared to men during the follow-up. By contrast, the global disease assessment evaluated by the patient and by the physician remained similar in both gender. When we analyze the DAS28 components separately, it was observed that this discrepancy was due mainly to the tender joints count and the ESR. CONCLUSIONS: Women with early RA have higher DAS28ESR scores as a result of higher tender joint counts and ESR. This may represent bias when assessing the response to treatment using the DAS28ESR.