An international survey of current management practices for polymyalgia rheumatica by general practitioners and rheumatologists

Abstract

Objectives To explore current management practices for polymyalgia rheumatica (PMR) by general practitioners (GPs) and rheumatologists including implications for clinical trial recruitment. Methods An English language questionnaire was constructed by a working group of rheumatologists and GPs from 6 countries. The questionnaire focused on: 1: Respondent characteristics, 2: Referral practices, 3: Treatment with glucocorticoids, 4: Diagnostics, 5: Comorbidities, and 6: Barriers to research. The questionnaire was distributed to rheumatologists and GPs worldwide via members of the International PMR/giant cell arteritis Study Group. Results In total, 394 GPs and 937 rheumatologists responded to the survey. GPs referred a median of 25% of their suspected PMR patients for diagnosis and 50% of these were returned to their GP for management. In general, 39% of rheumatologists evaluated patients with suspected PMR >2 weeks after referral, and a median of 50% of patients had started prednisolone before rheumatologist evaluation. Direct comparison of initial treatment showed that the percentage prescribing >25 mg prednisolone daily for patients was 30% for GPs and 12% for rheumatologists. Diagnostic imaging was rarely used. More than half (56%) of rheumatologists experienced difficulties recruiting people with PMR to clinical trials. Conclusion This large international survey indicates that a large proportion of people with PMR are not referred for diagnosis, and that the proportion of treatment naïve patients declined with increasing time from referral to assessment. Strategies are needed to change referral and management of people with PMR, to improve clinical practice and facilitate recruitment to clinical trials.

Treatment of Polymyalgia Rheumatica by Rheumatology Providers: Analysis from the American College of Rheumatology RISE Registry

“…Although glucocorticoid minimization has been the main driver of steroid-sparing agent use in patients with PMR, achievement of remission and potentially drug-free remission are targets that should be considered and that studies such as the methotrexate trials and the recent PMR glucocorticoid sparing (PMR-SPARE) trial suggest (8,18). However, current practices in the referral of patients with PMR to rheumatology (ie, low percentage of referrals, delayed timing of referrals, cumulative glucocorticoid use at time of referral) need to be examined to better understand the benefits of additional agents to minimize long-term glucocorticoid toxicities (7).…”

“…Despite the relatively high prevalence of PMR, there are little data on the use of steroid-sparing agents for PMR (3). A lack of large observational cohort studies, clinical trials, and the burden of most care for patients with PMR occurring in the primary care setting are potential contributing factors (7). Recently, a small number of randomized, placebo-controlled clinical trials have shown the efficacy (ie, disease remission and steroid-sparing effect) of interleukin (IL)-6 inhibitors (tocilizumab and sarilumab) and rituximab for PMR (8,9).…”

Referral of patients with suspected polymyalgia rheumatica: how complete is our view of ‘planet PMR?’

“…In the first scenario, patients are usually managed in primary care or rheumatology out-of-hospital settings,12 13 whereas the presence of systemic manifestations may lead to hospitalisation 14. An international online survey of 394 GPs and 937 rheumatologists showed that only 25% of patients with suspected PMR are referred from primary care to rheumatologists, with substantial variation between countries, ranging from 10% in the UK and the Netherlands to 60% in Italy and Romania, and up to 100% in Colombia (with wide variation in the percentage of referral also within countries) 15. A median of 50% (IQR 15%–75%) of patients were seen by a rheumatologist after starting treatment in the primary care setting.…”

“…Considerable differences are evident in the diagnostic approach taken by GPs and rheumatologists. More than 15% of GPs do not always request C reactive protein in patients with suspected PMR, more than 40% never or rarely check the presence of anticitrullinated protein antibodies, and about two-thirds never or rarely ask for any imaging examination 15. The approach to treatment by GPs and rheumatologists is also discrepant.…”

“…GPs prescribe a median prednisone starting dose of 20 mg instead of the median dose of 15 mg prescribed by rheumatologists. Notably, more than 30% of GP respondents used starting prednisone dosages higher than 25 mg per day,15 diverging from the starting dosage between 12.5 and 25 mg currently recommended by American College of Rheumatology and European Alliance of Associations for Rheumatology 16…”