Our approach to the diagnosis and treatment of polymyalgia rheumatica and giant cell (temporal) arteritis

Abstract

We believe there is a strong case for formalised collaborative care between GPs and rheumatologists in the management of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), which can be difficult conditions to diagnose and manage. Our rapid access diagnostic care pathways allow early referral of patients who appear to have PMR or GCA, before glucocorticoids are prescribed. Using set referral criteria, we identify patients with PMR who can follow our slow-reduction glucocorticoid regimen without recurrence or exacerbation in about 80% of cases, a much lower relapse rate than that reported using more rapid reduction regimens. We have a low threshold for performing a temporal artery biopsy in GCA and where possible defer treatment until this is done. Using this approach, we can establish a secure diagnosis in the vast majority of patients and refer them back to primary care for our standardised treatment regimens.

Development of a Provisional Core Domain Set for Polymyalgia Rheumatica: Report from the OMERACT 12 Polymyalgia Rheumatica Working Group

“…Its effects can be devastating to patients' lives (Box 1). Treatment with glucocorticoids remains the cornerstone of treatment 2,3 . The OMERACT PMR special interest group (SIG) was set up to identify a set of core outcome measures using OMERACT Filter 2.0 methodology 4 and builds on work previously presented at OMERACT 11 5 .…”

The role of the general practitioner and the out-of-hospital public rheumatologist in the diagnosis and follow-up of patients with polymyalgia rheumatica

“…Whether this is due to misclassification or to the presence of different presentations of the PMR syndrome is not clear. Quick et al found out that PMR is mostly diagnosed and managed in primary care, but observed that GPs have often trouble in identifying PMR (17). In this study, a review of 13 consecutive patients referred to hospital with PMR found that half of them had a different condition.…”

“…PMR is mainly diagnosed according to clinical features because there are no specific laboratory tests (16,17). However, even the clinical features are a combination of non-specific signs and symptoms, including aching and stiffness in the shoulder girdle, which fact can represent a complication in recognition of PMR.…”

“…In this study, a review of 13 consecutive patients referred to hospital with PMR found that half of them had a different condition. When the records of 47 PMR patients from six practices were reviewed, 25% showed only a gradual symptom improvement after treatment, suggesting that perhaps PMR was not the correct diagnosis; 38% of them were eventually referred to hospital care for improved management (17). In other centres, identification of diseases other than PMR during follow up has been reported in up to a quarter of patients (17).…”

“…When the records of 47 PMR patients from six practices were reviewed, 25% showed only a gradual symptom improvement after treatment, suggesting that perhaps PMR was not the correct diagnosis; 38% of them were eventually referred to hospital care for improved management (17). In other centres, identification of diseases other than PMR during follow up has been reported in up to a quarter of patients (17). In a study published by Helliwell et al in 2013, in 38% of patients diagnosed in primary care, the GP did not adopt any of the known classification criteria; in many cases, no information has been provided as to how the PMR diagnosis had been supported (6 o n l y been supported (6 Table I shows an example of tapering, in a patient with a good clinical response, using the two formulations of immediate-release prednisone available in Italy.…”