Usefulness of Methotrexate in the Reduction of Relapses and Recurrences in Polymyalgia Rheumatica: An Observational Study.

OBJECTIVES: Methotrexate (MTX) has been studied with conflicting results in patients with polymyalgia rheumatica (PMR). Our objective was to evaluate the effectiveness of MTX to reduce relapses and recurrences in patients with PMR. METHODS: This observational longitudinal cohort study included 94 consecutive patients with PMR. Patients were assigned to 3 groups according to the prescribed treatment: group 1, treated with glucocorticoids (GCs) alone; group 2, treated with GCs initially plus MTX after a relapse or recurrence; and group 3, treated with GCs plus MTX since diagnosis.Factors associated with a first relapse were studied in the population. To evaluate MTX effect, patients from group 2 were evaluated comparing results from the first treatment period (GCs alone) to the second treatment period with GCs plus MTX. RESULTS: Ninety-four patients were included. The median follow-up time was 21.3 months (interquartile range [IQR], 11.7-56.2). Fifty-three patients (56.4%) were in group 1, 33 (35.1%) in group 2, and 8 (8.5%) in group 3. We found that female sex had a tendency to be associated with a first relapse (p = 0.07).In group 2, 35 relapses were identified during the first treatment period and only 8 relapses during the combined treatment period (p < 0.001). In this group, after the addition of MTX, the GCs dose at relapse was lower (5.1 vs 3 mg/d, p = 0.02) and the time to accomplish remission was shorter (22.9 vs 8.7 months, p = 0.01). There were no differences in the number of recurrences. CONCLUSIONS: The use of MTX in PMR patients who already had a relapse reduced the number of future relapses and decreased the time to achieve remission. Adding MTX allowed a reduction of GCs dose at relapse.

Polymyalgia rheumatica: 125 years of epidemiological progress?

OBJECTIVES: On the 125th anniversary of the first recognised publication on polymyalgia rheumatica, a review of the literature was undertaken to assess what progress has been made from the point of view of the epidemiology of this disease and whether such studies have advanced our knowledge of its aetiopathogenesis and management. METHODS: The authors searched Medline and PubMed using the search terms 'polymyalgia rheumatica', 'giant cell arteritis' and 'temporal arteritis'. As much as possible, efforts were made to focus on studies where polymyalgia and giant cell arteritis were treated as separate entities. The selection of articles was influenced by the authors' bias that polymyalgia rheumatica is a separate clinical condition from giant cell arteritis and that, as yet, the diagnosis is a clinical one. RESULTS: This review has shown that, following the recognition of polymyalgia as a distinct clinical problem of the elderly, the results of a considerable amount of research efforts investigating the populations susceptible, the geographic distribution of these affected populations and the associated sociological and genetic elements that might contribute to its occurrence, polymyalgia rheumatica remains a difficult problem for the public health services of the developed world. CONCLUSIONS: Polymyalgia rheumatica remains a clinical enigma and its relationship to giant cell arteritis is no clearer now than it has been for the past 125 years. Diagnosing this disease is still almost exclusively dependent on the clinical acumen of a patient's medical attendant. Until an objective method of identifying it clearly in the clinical setting is available, uncovering the aetiology is still unlikely. Until then, clear guidelines on the future incidence and prevalence of polymyalgia rheumatica and the public health problems of the disease and its management, especially in relation to the use of long term corticosteroids, will be difficult to provide.

Polymyalgia rheumatica: 125 years of progress?

OBJECTIVES: On the 125th anniversary of the first recognised publication on polymyalgia rheumatica, a review of the literature was undertaken to assess what progress has been made from the point of view of the clinical care of affected patients. METHODS: The authors searched Medline and PubMed using the search terms 'polymyalgia rheumatica', 'giant cell arteritis' and 'temporal arteritis'. As much as possible, efforts were made to focus on studies where polymyalgia rheumatica and giant cell arteritis were treated as separate entities. The selection of articles was influenced by the authors' bias that polymyalgia rheumatica is a separate clinical condition from giant cell arteritis and that, as yet, the diagnosis is a clinical one. Apart from the elevation of circulating acute phase proteins, which has been recognised as a feature of polymyalgia rheumatica for over 60 years, the diagnosis receives no significant help from the laboratory or from diagnostic imaging. RESULTS: This review has shown that, following the recognition of polymyalgia as a distinct clinical problem of the elderly, the results of a considerable amount of research efforts including those using the advances in clinical imaging technology over the past 60 years, have done little to change the ability of clinicians to define the disease more accurately. Since the introduction of corticosteroids in the 1950s, there has been also very little change in the clinical management of the condition. CONCLUSIONS: Polymyalgia rheumatica remains a clinical enigma, and its relationship to giant cell arteritis is no clearer now than it has been for the past 125 years. Diagnosing this disease is still almost exclusively dependent on the clinical acumen of a patient's medical attendant. Until an objective method of identifying it clearly in the clinical setting is available, uncovering the aetiology is still unlikely, and until then, preventing the pain and stiffness of the disease while avoiding the problems of prolonged exoposure to corticosteroids is likely to remain elusive or serendipitous.

Anti-TNF therapy for polymyalgia rheumatica: report of 99 cases and review of the literature.

The objective of this study was to analyze the clinical, laboratorial, and therapeutical response of polymyalgia rheumatica (PMR) to anti-tumor necrosis factor (anti-TNF) treatment. We systematically searched English articles on the subjects of PMR who were treated with TNF blockers in Pubmed from 1994 to 2010. In addition, we reported on two patients with PMR who were treated by the Rheumatology Division of the Hospital das Clínicas da Faculdade de Medicina da Universidade in São Paulo, Brazil. Ninety-nine cases of patients with PMR treated with anti-TNF were reviewed. The age of these patients ranged from 63 to 84 years, and 70.7% of them were female. Disease duration varied from 10.5 weeks to 95 months, and time of follow-up varied from 2 weeks to 21 months. Infliximab was the anti-TNF of choice in three studies, while etanercept was in five. Time to response varied from 2 to 8 weeks. After anti-TNF treatment, prednisone reduction was observed in all studies. Clinical improvement was found in 7/7 studies, and laboratory improvement of at least 50% of inflammatory markers was observed in 6/7 studies. This study demonstrated a good clinical and laboratory response to anti-TNF therapy in patients with PMR, with or without glucocorticoid.

[Conditions mimicking polymyalgia rheumatica]. / Enfermedades que simulan polimialgia reumática.

OBJECTIVE: To examine the main clinical and laboratory data of patients initially diagnosed with polymyalgia rheumatica (PMR), which then developed another conditions. MATERIAL AND METHODS: We reviewed the clinical records of patients diagnosed with PMR in three hospitals in Argentina. Patients had a diagnosis of PMR if they met the following criteria: age ≥ 50 years, erythrocyte sedimentation rate (ESR) at the time of diagnosis > 40 mm, persistent pain and stiffness of at least one month of evolution in two of the following areas: neck, shoulders or proximal arms, hips or proximal lower limbs. Special attention was paid to symptoms or signs of "alarm" (beginning or during disease progression) for suspecting the presence of other non PMR disease within a period of ≤ 12 months. RESULTS: Sixteen of the 200 patients (8%) had other diseases during follow up. Malignancies (n=4) and rheumatic diseases (n=4) were the most common entities, in addition to infective endocarditis (n=1), narrow cervical canal (n=1), Parkinson's disease (n=1), statin-related myalgia (n=1), hypothyroidism (n=1), vitamin D deficiency (n=1) and Calcium Pyrophosphate Deposition Disease (CPDD) (n=2). The average length change of diagnosis was 4.5±3 months. Ten patients had no response to steroids and two had persistently elevated ESR. CONCLUSION: In this study we highlight the importance of recognizing signs and symptoms along with laboratory data and lack of response to treatment as suspects for the diagnosis of other disease manifestations in patients with PMR symptoms.

Polimialgia reumática: experiencia basada en 22 casos / Polymyalgia rheumatica: experience based on 22 cases

Introducción. La polimialgia reumática (PMR) se caracteriza por dolor y rigidez de las cinturas cervicoescapular y pelviana; preséntase en mayores de 50 años, asociada frecuentemente a arteritis de células gigantes (ACG), y tiene excelente respuesta a dosis bajas de corticosteroides. Objetivo. Evaluar sus características clínicas, de laboratorio, terapéuticas y evolutivas en nuestro medio. Pacientes y método: 22 pacientes diagnosticados según criterios establecidos y controlados entre 1998 y 2008. Según protocolo se analizan sexo, edad, diagnósticos previos, clínica, laboratorio, tratamiento y evolución. Resultados. Edad 52 a 81 años (mediana 69,3); predominio femenino (17/5), y 9,2 meses promedio de evolución prediagnóstico. Todos presentaron dolor y rigidez cervicoescapular y pelviana, 2 pacientes (9 por ciento) tuvieron artritis y 2 (9 por ciento), características clínicas de arteritis de células gigantes (ACG). El laboratorio fue inespecífico, excepto velocidad de sedimentación elevada entre 38 y 131 mm/hora (promedio 80,7). Todos tuvieron factor reumatoídeo (-) y anticuerpos antinucleares (-). Todos, excepto los portadores de ACG, respondieron a dosis bajas de corticosteroides (20 mg/día de prednisona o menos), con dosis de mantención entre 5 y 10 mg/día. Excelente evolución en todos, excepto uno, con desaparición de síntomas, normalización de VHS y reintegración a actividades previas. Conclusiones. La PMR constituye un diagnóstico diferencial en personas mayores de 50 años con dolor de cintura escapular y pelviana, que suele asociarse con ACG. El diagnóstico se basa en criterios bien establecidos, destacando la VHS persistentemente alta y la respuesta a dosis bajas de corticosteroides, que es además la terapéutica de elección.

Polymyalgia rheumatica (PMR) is characterized by cervicoscapular and pelvic pain and rigidity, it manifests in people older than 50 years and is frequently associated with giant cell arteritis (GCA). It responds very well to low doses of corticosteroids. Objective: Evaluate clinical, laboratory, therapeutic and evolutionary characteristics in our environment. Patients and method: 22 patients diagnosed according to set criteria and controlled between 1998 and 2008. Sex, age, previous clinical and laboratory diagnosis, treatment and evolution were analyzed. Results: Age 52 to 81 (average 69.3); 17 females,5 males; and 9.2 month average prediagnostic evolution. All presented cervicoscapular and pelvic pain and rigidity, 2 patients (9 percent) had arthritis, and 2 (9 percent) presentedclinical characteristics of GCA. Laboratory tests were nonspecific, except for high sedimentation speed between 38 and 131 mm/hour (average 80.7). All patients presented rheumatoid factor (-) and antinuclear antibodies (-). All, except GCA carriers, responded to low doses of corticosteroids (20 mg/day or less of Prednisona), followed by a maintenance dose of 5 - 10 mg/day. Evolution was excellent in all patients except one, symptoms disappeared, ESR normalized and patients were reintegrated to their previous activities. Conclusions: PMR constitutes a differential diagnosis in people over 50 years of age, with cervicoscapular and pelvic pain, and is commonly associated with GCA. Diagnosis is based on well established criteria, with persistently high ESR and response to low doses of corticosteroids - the treatment therapy of choice - among the most significant.

Peripheral musculoskeletal manifestations in polymyalgia rheumatica.

OBJECTIVES: The objectives of this study were to evaluate the frequency and characteristics of the peripheral musculoskeletal manifestations in polymyalgia rheumatica (PMR), evaluate if PMR with peripheral synovitis represents a subset with a more severe disease, and examine for clinical and laboratory characteristics at onset of PMR that might later predict rheumatoid arthritis (RA). PATIENTS AND METHODS: Patients were diagnosed with PMR according to the 1982 Chuang criteria. Patients were followed up between 1990 and 2002. The following musculoskeletal manifestations at onset and during the follow up were considered: peripheral synovitis, distal extremity swelling with pitting edema, carpal tunnel syndrome, and distal tenosynovitis. RESULTS: Thirty-eight of the 74 patients (51%) showed distal musculoskeletal symptoms: 29 (39%) had peripheral synovitis, 4 (5%) presented pitting edema, 4 (5%) experienced carpal tunnel syndrome, and one (1.3%) had distal tenosynovitis. These manifestations resolved completely after corticosteroid therapy was initiated. Peripheral synovitis was oligoarticular and often transient. The joints most frequently involved were the wrist, metacarpophalangeal, and knee. Erythrocyte sedimentation rate (ESR) was normal in 7 patients. When comparing patients with PMR with and without peripheral synovitis, no statistically significant differences were found in the studied variables. Through the first year of follow up, 7 patients fulfilled the American College of Rheumatology 1987 criteria for RA, 2 patients developed giant cell arteritis, and 3 had associated malignancy. Patients who developed RA had statistically significantly increased presence of persistent synovitis and a smaller decrease in mean ESR after treatment with corticosteroids. CONCLUSION: Fifty-one percent of the patients with PMR presented distal musculoskeletal manifestations, with peripheral synovitis being the most frequent one. Patients with PMR with peripheral synovitis did not represent a high-risk subgroup with more severe disease. Seven patients who developed criteria for seronegative RA within the first year of follow up had presented statistically significant persistent synovitis compared with those who continued as PMR and also showed a smaller initial decrease in mean ESR after steroid treatment was initiated. The absence of persistent arthritis and the benign course of the arthritis permit the distinction of PMR from other inflammatory arthropathies.

[Polymyalgia rheumatica revisited]. / Actualización en polimialgia reumática.

Polymyalgia rheumatica is an inflammatory disorder that usually affects persons over the age of 50 causing proximal muscle pain and stiffness, and an elevated erythrocyte sedimentation rate. Although increasingly recognized in this age group, it remains a diagnosis of exclusion and although several diagnostic criteria have been proposed, none has been clearly accepted. While polymyalgia rheumatica is associated with giant cell arteritis, obtaining a temporal artery biopsy is not recommended in patients with polymyalgia rheumatica without symptoms of giant cell arteritis. Early diagnosis and low dose corticosteroid therapy improve patients' clinical features and functional status. Treatment usually lasts between 12 and 24 months and the majority of patients manage to discontinue treatment completely.

Actualizacion en polimialgia reumática / Polymyalgia rheumatica revisited

Polymyalgia rheumatica is an inflammatory disorder that usually affects persons over the age of 50 causing proximal muscle pain and stiffness, and an elevated erythrocyte sedimentation rate. Although increasingly recognized in this age group, it remains a diagnosis of exclusion and although several diagnostic criteria have been proposed, none has been clearly accepted. While polymyalgia rheumatica is associated with giant cell arteritis, obtaining a temporal artery biopsy is not recommended in patients with polymyalgia rheumatica without symptoms of giant cell arteritis. Early diagnosis and low dose corticosteroid therapy improve patients clinical features and functional status. Treatment usually lasts between 12 and 24 months and the majority of patients manage to discontinue treatment completely (AU)

Arteritis de células gigantes y polimialgia reumática / Giant cell arteritis and rheumatic polymialgia

Se analizan las principales características tanto epidemiológicas como clínicas de los cuadros aparentemente infrecuentes pero no excepcionales en nuestro medio . Ellos son la arteritis de células gigantes o arteritis temporal y la polimialgia reumática. Ambos afectan a mayores de 50 ó 60 años y suelen presentarse en forma concomitante, lo que ha hecho precisar que podrían ser manifestaciones clínicas de una sóla entidad clínica. Se mencionan los principales elementos diagnósticos de laboratorio, destacando la importancia práctica de la velocidad de sedimentación en el control de la evolución y de las alternativas histológicas en la biopsia de arteria temporal. Se señala la utilidad en ambos cuadros del tratamiento esteroidal, el que en caso de la arteritis temporal debe instituirse lo más precozmente posible para evitar el compromiso ocular que es grave. Se enfatizan los inconvenientes que reviste, en los pacientes de edad, la administración de corticoides por largos períodos o en forma indefinida

Padecimientos reumaticos extraarticulares y una alternativa terapeútica en su tratamiento con un antinflamatorio topico: diclofenaco dietilamoni / Rheumatic extra-articular diseases and a therapeutic alternative in their treatment with a topical antiinflammatory: dietylamonium diclofemac

En este estudio ciego comparativo de 40 pacientes con enfermedades extraarticulares reumáticas, se observaron cambios significativos de los parámetros evaluados, presentando diferencias relevantes entre grupos (diclofenaco dietilamonio y naproxén sódico) a favor del diclofenaco. El número de los efectpos secundarios reportado fue sensiblemente menor en el grupo tratado con diclofenaco dietilamonio comparado con el grupo tratado con naproxén sódico. Estos resultados señalan que el diclofenaco dietilamonio es más efectivo y mejor tolerado en pacientes que cursen con enfermdedades extraarticulares reumáticas y representa una alternativa terapéutica poderosa

Estudio comparativo doble-ciego tenoxicam-piroxicam para el tratamiento del reumatismo extraarticular / A comparative-double blind study of tenoxicam pyroxicam in the treatment of extraarticular rheumatism

Se incluyeron 30 pacientes de uno u otro sexo, con padecimiento reumático extraarticular para llevar a cabo un estudio doble-ciego, comparativo entre tenoxicam y piroxicam, valorando eficacia clínica y tolerancia de una dosis única de 20 mg al día de ambos preparados, adminsitrados antes del desayuno durante 14 días. Los parámetros valorados fueron: dolor espontáneo y al movimiento, sensibilidad aumentada a la presión, aumento local de volumen y limitación funcional. En ambos grupos la respuesta clínica fue evidente ya desde el segundo día de tratamiento; al finalizar las dos semanas la respuesta global no mostró diferencia estadísticamente significativa entre ambos grupos. Sin embargo, tenoxicam fue mejor tolerado ya que ningún paciente presentó efectos indeseables mientras que con piroxicam, dos pacientes desarrollaron dermatosis que obligó a suspender el medicamento al cuarto y décimo días respectivamente