BackgroundPolymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related diseases. PMR occurs in approximately 50 % of patients with GCA1; however the prevalence of subclinical GCA in PMR has not yet been widely studied.ObjectivesThe aim of our multicenter, prospective study was to determine the prevalence of subclinical GCA in newly diagnosed PMR, using vascular ultrasound (US) as a diagnostic tool.MethodsEight European centers participated in the study. The studied cohort represented consecutive newly diagnosed patients with PMR who fulfilled 2012 EULAR/ACR Provisional Classification Criteria for Polymyalgia Rheumatica2 without symptoms or signs suggestive for GCA. All patients underwent ultrasound (US) of both hips and shoulders, as well as of four bilateral arterial territories (i.e. temporal, common carotid, subclavian and axillary arteries). Patients with positive halo signs were considered to have subclinical GCA 3. An intima-media thickness ≥0.34 mm for frontal and parietal TA, 0.42mm for common TA, and ≥1 mm for common carotid, axillary and subclavian arteries for positive result. Clinical demographic and laboratory characteristics of the PMR pure group were compared with the PMR/GCA patient group.ResultsA total of 258 patients were included, 137 (53.1%) females with a mean age of 73±8.4 years. Table 1 shows the main differences in PMR patients with and without subclinical GCA. The only statistical significant difference between the two groups was the higher prevalence of morning stiffness > 40 minutes in the pure PMR group (p<0.05). A halo sign was found on at least one of the examined arteries in 56/258 patients (21.7%).The different subtypes of vessel involvement were available in 216 cases. Data compatible with the diagnosis of GCA was found in 41 cases (19%): 10 (24.3%) had only temporal artery involvement (“cranial” GCA), 27 (65.8%) had an extra-cranial artery involvement and 4 (9.8%) a mixed form with both cranial and extra-cranial artery involvement (Figure 1).Table 1.Clinical and demographic characteristicsFigure 1.Subtypes of subclinical GCA in PMR in 216 patients with cranial and extra-cranial examinationConclusionOne fifth of PMR patients without symptoms or signs of GCA have ultrasound findings consistent with the diagnosis of GCA. Subclinical GCA in PMR shows a predilection for extra-cranial artery involvement.References[1]Buttgereit F et al. JAMA. 2016;315:2442-58.[2]Dasgupta B et al. Arthritis & Rheumatism. 2012; 64:943–954.[3]De Miguel E et al. Rheumatology 2018; 57:318-321.AcknowledgementsTo the GCA/PMR study groupDisclosure of InterestsNone declared
BackgroundPolymyalgia rheumatica (PMR) can be associated with giant cell arteritis (GCA), even in the absence of clinical suspicions of vasculitis. In addition, some studies have shown an association of PMR with the predominantly large vessel involvement.ObjectivesThe objective of our study was to assess the presence of subclinical GCA in patients with PMR and to compare its pattern of vascular involvement to patients with classical GCA.MethodsEight rheumatology European centers participated in the study. Cohort A represented consecutive newly diagnosed patients with PMR who fulfilled the 2012 EULAR/ACR Provisional Classification Criteria for Polymyalgia Rheumatica2 and had no symptoms or signs suggestive of GCA. Ultrasound (US) examination of four vessel territories (i.e. temporal, carotid, subclavian and axillary arteries) was performed bilaterally. Cohort B included all consecutive patients with the diagnosis of GCA evaluated on the fast-track clinic of one of the hospitals (HULP). The halo sign was considered as positive US finding for GCA3. In addition, intima-media thickness of arteries was measured, with a cut-off ≥0.34 mm for temporal arteries (TA) frontal and parietal, 0.42mm for common TA, and ≥1 mm for common carotid, axillary and subclavian arteries for positive result. The clinical characteristics of PMR patients were recorded and the frequency of subclinical GCA determined.ResultsCohort A included 41 PMR patients with subclinical GCA. Cohort B was formed by 97 GCA. The characteristics of the patients are shown in the Table 1. Figure 1 shows the different subtypes of vessel involvement in patients with PMR and subclinical GCA and in patients of the fast-track clinic with the diagnosis of GCA in a single hospital.Figure 1.Subtypes of vessel affectation in Subclinical GCA in PMR and in classical GCATable 1.Clinical characteristics of patients of Cohort A (Subclinical GCA in PMR n = 41/216) and B (GCA in the fast-track clinic n = 97)Cohort A (n = 41)Cohort B (n = 97)Sex female (%)17 (41.5%)53 (54.6%)Age (years) mean ± SD74±6.779 ± 12CRP mg/L49.6±49.146 ± 81.6Polymyalgia rheumatica41 (100%)47 (48.5%)Constitutional symptoms19 (35.18%)35 (36.1%)Subclinical PMR has a predilection for affectation of large vessels, followed by isolated cranial pattern (ie. Isolated temporal artery involvement) and by the mixed (cranial and extra-cranial) form. On the contrary, in classical GCA an isolated cranial involvement represents the more common pattern, followed by the mixed and finally isolated large vessel involvement.ConclusionSubclinical GCA in PMR shows a principal isolated extra-cranial involvement and with clearly different pattern than classical GCA.AcknowledgementsTo the GCA/PMR study groupDisclosure of InterestsNone declared
BackgroundSubclinical giant cell arteritis (GCA) in polymyalgia rheumatica (PMR) is found in the 22.8% of patients on ultrasound examinations. The outcome and the optimal management of subclinical giant cell arteritis (GCA) in patients with polymyalgia rheumatica (PMR) have not been defined yet.ObjectivesThe aim of this study was to investigate the short-term outcome of PMR patients with concurrent subclinical GCA that were included in our multicenter project on the prevalence, characteristics and outcome of subclinical GCA (diagnosed by vascular ultrasound) in PMR[1].MethodsWe analyzed follow up data at 3, 6, 12 and 18 months of consecutive PMR patients from 7 European rheumatology centers. All patients fulfilled 2012 EULAR/ACR Provisional Classification Criteria for Polymyalgia Rheumatica and they had not symptom of clinical GCA. Patients were stratified into two groups: pure PMR and PMR with subclinical GCA, and the outcome between these two groups were compared. A relapse was defined as clinical and/or laboratory worsening of the disease after the initial remission and minor and major relapse EULAR definition was used[2].ResultsWe included 116 PMR patients (47 with concurrent subclinical GCA and 69 with pure PMR) followed for a median (IQR) of 21 (17; 23) months. We observed relapses in 35/116 patients (30.2%), 27/47 (57.4%) in PMR with subclinical GCA and 8/69 (11.6%) in pure PMR group (p<0.001). All relapses in the pure PMR group were minor relapses, whereas we observed 2 major relapses in the subclinical GCA group. The dose of corticosteroids used at the baseline visit was significantly higher in the GCA subclinical group, but tapering of steroids occurred faster than recommended by clinical guidelines[2]. Prednisone dose was significantly higher in patients with PMR and subclinical GCA than in patients with pure PMR both at baseline and at month 6 (Table 1). In patients with PMR with subclinical GCA mean starting dose of prednisone was 32.2±16.1 mg in those who relapsed and 36.2±12.8 in those who maintained remission (p=0.166); at 3 months, it was 13.2±7.1 and 18.2±7.9, respectively (p<0.05). Three patients in the PMR with subclinical GCA group received biological therapy at diagnosis; one of them had a minor relapse.Table 1.Patients characteristicsPure PMR(n=69)Subclinical GCA/PMR(n=47)pAge years (mean ± SD)71.2±8.074.8±7.60.079Sex (females %)59%52%0.526Relapses n (%)8/69 (11.6%)27/47 (57.4%)0.001Minor Relapses n (%)8/69 (11.6%)25/47 (53.2%)0.001Major Relapses n (%)02/47 (4.2%)Steroids basal (mean ± SD))18.3±9.134±14.80.001Steroids month 3 (mean ± SD)9.9±5.114.6±8.30.001Steroids month 6 (mean ± SD)5.6±2.18.8±6.80.037Steroids month 12 (mean ± SD)1.7±2.18.0±14.20.062Steroids month 18 (mean ± SD)1.1±1.83.6±5.60.09Steroids = mg prednisone; SD = standard deviation; n= number of patientsConclusionPMR patients with subclinical GCA had a significantly higher number of relapses during the follow-up than pure PMR group. These results suggest that subclinical GCA in PMR should be treated in the same manner as clinically overt GCA.References[1]De Miguel et al. Prevalence of subclinical giant cell arteritis in patients with polymyalgia rheumatica. Ann Rheum Dis 2022; volume 81, supplement 1, page 122.[2]Hellmich B et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020 Jan;79:19-30.AcknowledgementsWe would like to thank to the GCA/PMR study group for her contributions to the development of collaborative studies.Disclosure of InterestsNone Declared.
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