SUMMARYPolymyalgia rheumatica (PMR) is a chronic inflammatory disease characterized by shoulder and pelvic girdle pain. Its onset peaks around the age of 75; the prevalence increases until the age of 90 and it is more frequent in females. Diagnosis is mostly performed on the basis of symptoms. An increase of serum inflammatory markers is indicative, but not essential, while therapy is mainly based on glucocorticoids. Since there is no universal agreement about diagnostic criteria for PMR, its detection is still difficult. There are discordant opinions about the fact that PMR can be recognised and managed by general practitioners (GPs), while patients with atypical features need to be referred to the rheumatologist. In the Italian setting, the absence of recent epidemiological studies is associated with the total lack of a research protocol in primary care, from which relevant information could be derived. The out-of-hospital public rheumatologist is a peculiar figure of the Italian National Health System, who takes care of outpatients. Although differences between the different Italian regional health services exist, this professional figure has proved to be effective in reducing delay and increasing accuracy in PMR diagnosis.

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BackgroundPolymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. Glucocorticoid (GC) treatment is effective but often prolonged, with associated side effects. Data on risk factors of poor prognosis are scanty: in particular it is not known if the pattern of clinical presentation can influence PMR outcome.ObjectivesTo test the hypothesis that clinical presentation of PMR can predict its outcome.Methods394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird's criteria, visited between 1990 and 2014 by the same clinician were studied. Median follow up was 13.8 months (range 1–250 months). Clinical features recorded at disease presentation included involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; vi) two or more of the previous locations; v) with giant cell arteritis (GCA); or vi) with acute onset, defined as completion of full symptoms and signs in ≤72h. PMR outcome was evaluated by considering: i) duration of follow-up; ii) appearance of peripheral arthritis; iii) appearance of GCA; iv) number of exacerbations/ relapses; v) cumulative dosage of GC; vi) use of methotrexate (MTX); and vii) death.ResultsAt multivariate analysis, acute onset predicted a longer follow-up duration (p=0.007) and death (p=0.037); involvement of the spine predicted longer follow up duration (p=0.001) and use of MTX (p=0.018); presentation at the pelvic girdle predicted a high number of exacerbations/relapses (p=0.034) and association therapy with MTX (p=0.009); onset in multiple locations predicted a high number of exacerbations/relapses (p=0.03); presentation with GCA predicted a higher cumulative dosage of GC (p=0.0001) and use of MTX (p=0.027).ConclusionsApart from the obvious association between concomitant GCA and negative prognosis of PMR, other clinical characteristics at disease onset influence outcome. In particular, the initial presentation with multiple locations, including spine and pelvic girdle, resulted in longer follow-up, more relapses, and need of MTX treatment, whereas the classic one with only shoulder girdle involvement was associated with a milder disease. An acute onset was also a negative prognostic factor. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR.Disclosure of InterestNone declared

BackgroundPolymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. In its classical form, the shoulder girdle is affected, associated or not with pelvic and spinal pain. The latter two locations can occasionally precede shoulder involvement. It is not known if the pattern of clinical presentation is related to disease severity at onset.ObjectivesIn this study, disease severity of PMR has been correlated with clinical characteristics at presentation.Methods394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird's criteria, visited between 1990 and 2014 by the same clinician were studied. Clinical features recorded at disease presentation included initial involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; iv) two or more of the previous locations; v) presence of giant cell arteritis (GCA); vi) acute onset, defined as completion of full symptoms and signs in ≤72h; or vii) peripheral arthritis. Disease severity of PMR was evaluated by considering: i) weight loss; ii) fever; iii) morning stiffness (MS); iv) ESR; v) CRP; and vi) initial dose of prednisone.ResultsAcute onset and classical involvement of the shoulder girdle were not associated with our indicators of PMR severity. By contrast, onset in the pelvic girdle (p=0.002), simultaneous onset in multiple locations (p=0.006), peripheral arthritis (p=0.045) and GCA (p=0.0004) were associated with a higher initial dose of prednisone; multiple locations onset correlated also with MS (p=0.044).ConclusionsThe presentation with multiple locations, including column and pelvic girdle, peripheral arthritis, and GCA resulted in a more severe onset at least in the perception of the clinician who used a higher initial dose of prednisone. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR.Disclosure of InterestNone declared