Usefulness of the disease activity scores for polymyalgia rheumatica for predicting glucocorticoid dose changes: A study of 243 scenarios

Abstract

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 >10 minutes (100% sensitivity, 99.3% specificity); PMR-AS >7 (98.1% sensitivity, 94.3% specificity); VASph >2.25 (94.2% sensitivity, 83.6% specificity); and CRP level >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.

Performance of the polymyalgia rheumatica activity score for diagnosing disease flares

“…The 9.35 value was a better cutoff than the 10.96 value for several reasons: the PMR-AS value was overestimated in the 82 first visits because patients with first flares (at diagnosis), which were included in these visits, had higher disease activity than did patients with repeat flares; in the ROC curve analysis excluding the visit at diagnosis (first flare), 9.45 was the best PMR-AS cutoff (sensitivity 95.2% and specificity 90.7%); and observations were probably independent or nearly independent, so that analyzing the overall visits was legitimate. An increase Ն6.6 in PMR-AS between 2 visits showed even better diagnostic performance, in keeping with the results of our clinical vignette study (4). Using a single absolute PMR-AS value to diagnose flares is possible only in patients with previously controlled disease; an absolute value Ͼ9.35 with previously uncontrolled disease indicates high disease activity but does not necessarily reflect a flare.…”

“…PMR-AS values Ն7 defined a flare with 98.1% sensitivity and 94.3% specificity. However, a PMR-AS increase Ͼ4.2 between 2 visits was better than a PMR-AS score Ն7 in diagnosing flares (4). The next step was to evaluate the ability of the PMR-AS to diagnose disease flares in a sample of actual patients.…”

Outcome Measures in Polymyalgia Rheumatica. A Systematic Review

“…Similarly, another component of PMR-AS is the patient pain VAS; and patient global VAS is usually strongly correlated with pain VAS. PMR-AS also showed very good internal consistency in 2 different cohorts (Cronbach-α 0.90 and 0.88) 6 and demonstrated reliability 3,33,53 . GC therapy.…”

“…A variety of outcomes have been used to assess disease activity, including clinical features (pain and morning stiffness), ultrasonography (US) variables, and laboratory measures such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and interleukin-6 (IL-6) levels. Composite scores of disease activity 3 , and definitions of good response, remission and relapse have been proposed 3,4,5,6 . However, these measures have not yet been extensively validated in PMR and do not incorporate patient viewpoints.…”

Diagnosis of Anterior Cruciate Ligament Rupture in an Emergency Department

“…Finally, the emergency physician recorded the diagnosis, specifying whether the ACL was ruptured, and evaluated his or her confidence with the diagnosis on a scale from 0 to 10, as previously reported for other musculoskeletal diseases. 16 In all patients with knee injuries, the initial treatment consisted of analgesics, immobilization of the injured knee, and use of crutches for walking even when the emergency physician diagnosed ACL rupture.…”