Introduction The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR-BHPR) guidelines for management of polymyalgia rheumatica (PMR) were published in 2010, aiming to provide guidance for diagnosis, management and disease monitoring. Its management is currently subject to wide variations in clinical practice, with management crossing the boundaries between primary and secondary care. Symptoms of and/or exposure to serious infections should be assessed in all patients starting glucocorticoids, considering the local prevalence of these infections. 7. Difficult-to-treat rheumatoid arthritis: contributing factors and burden of disease, A rare case of small-vessel necrotizing vasculitis of the bone marrow revealing granulomatosis with polyangiitis, Defining colchicine resistance/intolerance in patients with familial Mediterranean fever: a modified-Delphi consensus approach, Real-world single centre use of JAK inhibitors across the rheumatoid arthritis pathway, The management of Sjögren’s syndrome: British Society for Rheumatology guideline scope, About the British Society for Rheumatology, Potential organizational barriers to implementation, Cost and cost-effectiveness implications for implementation, Mechanism for auditing compliance with the guideline, Statement of contribution of the literature review team, Presentation and dissemination of final guidelines, https://doi.org/10.1093/rheumatology/kez672, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pdf, https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model, Receive exclusive offers and updates from Oxford Academic, British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive summary, Comment on: British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis, Ultrasound in the diagnosis and management of giant cell arteritis, CD3 immunohistochemistry is helpful in the diagnosis of giant cell arteritis, Atherosclerosis as a potential pitfall in the diagnosis of giant cell arteritis, Services for spondyloarthritis: a survey of patients and rheumatologists. 2019 Aug 22;10:1981. doi: 10.3389/fimmu.2019.01981. MMW Fortschr Med. Patients should receive advice on diet, physical activity and stopping smoking. Therapy-Related Imaging Findings in Patients with Sarcoma. Rheumatology 2010; 49:1594. Comparing the single-daily and alternate-day treatment groups, at 4 weeks the single-daily group had higher remission rates at 4 weeks [RR 2.67 (CI 1.32, 5.39)] and lower relapse rates [RR 0.11 (CI 0.02, 0.80)] (QoE +). Please enable it to take advantage of the complete set of features! An individual patient data meta-analysis relating to these three RCTs was also identified [100] and included in this review because it is a more efficient use of the data than meta-analysis using published reports. A typical glucocorticoid tapering schedule for GCA, Aim to reach 20 mg prednisolone once the patient has been in remission for 4–8 weeks, If symptoms suggestive of GCA relapse occur during taper, consult Table 3. BSR Guidelines for Giant Cell Arteritis Save. Splitting the dose over the day does not seem to confer benefit and potentially carries risks of disturbance of diurnal rhythms, including sleep [96, 97]. QoE: +. Patients receiving placebo were treated with one of two alternative prednisone tapering schedules, by which prednisone cessation was achieved at either 6 months or 1 year if the patient remained relapse-free. More Primary Care research Into PMR. No benefit of the drug was observed regarding cumulative glucocorticoid dose, acute phase reactants or patients’ and physicians’ global assessments (all QoE +). Finally cortisone therapy leads to right track]. Each follow-up visit should include at least a full history, targeted physical examination and measurement of at least a full blood count, ESR and/or CRP, plus follow-up of any abnormalities relevant to the individual patient as well as drug-specific screening for toxicity. Selection of the most appropriate confirmatory diagnostic test(s) therefore requires an assessment of the pretest probability as outlined elsewhere [77]; if both ultrasound and biopsy are possible, an approach to this is suggested in Fig. Published by British Society for Rheumatology (BSR), 01 November 2009 Aims: The aim of these guidelines is a safe and specific diagnostic process for polymyalgia rheumatica (PMR), using continued assessment, and discouragement of hasty initial treatment. PMR is the most common inflammatory rheumaticdisease in the elderly and is one of the biggest indicationsfor long-term steroid therapy. Hoffman GS, Cid MC, Rendt-Zagar KE et al. Data from the Temporal Artery Biopsy versus Ultrasound in the Diagnosis of Giant Cell Arteritis study [19] suggested significant variation between pathologists in the interpretation of temporal artery biopsy histology, so where biopsy findings are ambiguous (e.g. The consensus score was defined as the mean of all scores received. Does dapsone have a role in the treatment of temporal arteritis with regard to efficacy and toxicity? Introduction The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR-BHPR) guidelines for management of polymyalgia rheumatica (PMR) were published in 2010, aiming to provide guidance for diagnosis, management and disease monitoring. Patients should be advised about alteration of their glucocorticoid dose in intercurrent illness, especially including advice for seeking emergency attention if they suffer a vomiting illness necessitating parenteral glucocorticoid. Conditional recommendation: 18F-FDG-PET, MRA, CTA or axillary artery ultrasound may be used to evaluate involvement of the aorta and its proximal branches. There is insufficient evidence to recommend any other oral immunosuppressive agent in GCA, including azathioprine, leflunomide or mycophenolate mofetil. guideline. Therefore clinicians are advised to use their own discretion regarding selection of patients for aortic imaging. Improving bone health and muscle strength through weight-bearing exercises 2. A lower daily glucocorticoid dose at the end of the follow-up (52 weeks) was found in the intervention group compared with the control group [mean dose difference 3 mg (CI 4.32, 0.28), QoE +]. CRP scheint der sensitivere Maker zu sein. I. Steroid regimens in the first two months, Daily and alternate-day corticosteroid regimens in treatment of giant cell arteritis: comparison in a prospective study, Influences of corticosteroids, dexamethasone and hydrocortisone on sleep in humans, Population-based assessment of adverse events associated with long-term glucocorticoid use, Combined treatment of giant-cell arteritis with methotrexate and prednisone. Outcomes deemed as critical (i.e. Two studies (140 patients with suspected GCA, of whom 67 were diagnosed with GCA) compared the ultrasound ‘compression’ sign of temporal arteries with ACR criteria–based diagnosis of GCA, giving a pooled sensitivity of 79% (95% CI 67, 88) and a pooled specificity of 100% (95% CI 95, 100) [57, 66]. In practice, constraints of the healthcare system may create challenges to widespread implementation of this guideline. However, this should be adapted for the individual patient. In: Rausch Osthoff AK, Niedermann K, Braun J et al. Patients without a history of chicken pox (varicella zoster virus infection) should be advised to avoid close contact with people who have chickenpox or shingles and to seek urgent medical advice if they have been exposed. Where significant clinical heterogeneity was present, analysis of individual studies and/or subanalyses investigating studies with comparable design and quality was conducted. The ultrasound halo diminishes in size during the first week of glucocorticoid therapy, indicating that the sensitivity of the test is likely to depend on the delay between initiation of glucocorticoid therapy and the ultrasound test [19]. 4. Two RCTs addressed the question of whether intravenous glucocorticoids should be given in patients with new-onset, uncomplicated GCA (i.e. Table 2 is an example of a typical glucocorticoid taper schedule, based on that described in the 2010 BSR guidelines for GCA and similar to the control arm of a recent GCA clinical trial. 40–60 mg oral prednisolone: initial dose for patients with active GCA, Continue at same dose until GCA symptoms and acute phase markers resolve, In clinical remission and >20 mg prednisolone, In clinical remission, >10 mg prednisolone but <20 mg, Reduce daily dose by 2.5 mg every 2–4 weeks, In clinical remission and on ≤10 mg prednisolone, Reduce daily dose by 1 mg every 1–2 months, Possible GCA relapse without ischaemic manifestations, Return to previous higher prednisolone dose, Possible GCA relapse with ischaemic manifestations, Consider high-dose oral prednisolone (40–60 mg) with or without glucocorticoid-sparing agent, Weight loss, fever, night sweats, anaemia, persistent acute phase response, new/recurrent PMR symptoms, limb claudication, abdominal pain or back pain, Possible GCA-related inflammation of the aorta and/or its proximal branches, Investigate with vascular imaging (MRI, CT or FDG-PET/CT); consider increasing oral prednisolone and/or adding glucocorticoid-sparing agent, Copyright © 2020 British Society for Rheumatology. Contraindications and special considerations. Nesher G, Nesher R, Mates M, Sonnenblick M, Breuer GS. Mackie SL, Hensor EM, Morgan AW, Pease CT. Hachulla E, Boivin V, Pasturel-Michon U et al. bruits, different blood pressures in the two arms and limb claudication, Ophthalmological evaluation for patients with transient or permanent visual loss or diplopia, History of comorbidities and medications that might predispose to glucocorticoid-related adverse effects, including infection, hypertension, diabetes, osteoporosis, low-trauma fracture, dyslipidaemia, peptic ulcer and psychiatric adverse effects, Features that may suggest an alternative diagnosis, e.g. Due to the substantial differences in study design, efficacy outcomes were not meta-analysed. BSR guidelines (2009) specify active infection, active cancer and giant cell arteritis (GCA) as the core exclusion criteria. Patients treated for GCA should be evaluated for features of the disease relevant to the prognosis, such as clinical and laboratory features of a marked inflammatory response at diagnosis, ischaemic manifestations such as transient visual loss or jaw/tongue claudication and signs or symptoms indicating involvement of the aorta and its proximal branches, and for comorbidities relevant to treatment, such as diabetes mellitus, hypertension and bone fracture risk. Evidence generated from prospective diagnostic accuracy studies, RCTs and longitudinal cohort studies investigating prognostic factors started as high quality but was downgraded if any of the above limitations was present. van Assen S, Agmon-Levin N, Elkayam O et al. Large-vessel dilatation in giant cell arteritis: a different subset of disease? Clinical diagnosis is based on clinical symptoms, signs and laboratory tests, each of which are imperfect markers for GCA. Diagnostic accuracy may be expressed as sensitivity and specificity, or as a likelihood ratio; this information can be combined with the pretest probability (established on clinical grounds) to select and interpret the results of confirmatory diagnostic tests. NIH Jover JA, Hernandez-Garcia C, Morado IC et al. Contrast-enhanced CT of the chest and abdomen is also often used in clinical practice to screen for deep infection or occult malignancy. At least 10% of patients received higher doses with a tapering regime non-aligned to guideline recom-mendations. Longitudinal clusters of pain and stiffness in polymyalgia rheumatica: 2-year results from the PMR Cohort Study. Prior to defining the Population, Intervention, Comparator, Outcome (PICO) questions, stakeholders were consulted regarding outcomes of importance in GCA [15]. Both biologic and non-biologic therapies used alongside glucocorticoid treatment would incur additional costs due to the requirements for regular blood monitoring. ... BSR Guidelines Protocol. Patients often describe difficulty getting dressed or discomfort when turning in bed at night that interferes with sleep. Notably a large prospective UK study assessing the diagnostic value of ultrasound addressed this issue by blinding the patient, the treating clinician and the investigator to the ultrasound result [19]. The same glucocorticoid dose was used in the first 5 days, but the rate of tapering thereafter differed between treatment groups. Screening tests for infection and osteoporosis to be considered in light of relevant local and national guidelines. Dasgupta B, Matteson EL, Maradit-Kremers H. Management guidelines and outcome measures in polymyalgia rheumatica (PMR). No RCTs of cholesterol-lowering agents for GCA were found. 2019 May 14;20:e46. For a high clinical probability of GCA, a positive ultrasound alone may be sufficient, as illustrated here; however, in these cases it is still acceptable to perform biopsy in addition to ultrasound in order to further increase diagnostic certainty. Consensus score: 8.81. Each outcome was graded based on its relative importance for clinical decision making on a 1–9 point scale [15]. 2003 Apr 24;145(17):12-3. 5. on the basis of their comorbidity profile or other risk factors for glucocorticoid-related toxicity, including neuropsychiatric glucocorticoid-related adverse effects, previous fragility fractures or difficult-to-control diabetes mellitus). Two members of each group independently performed screening, inclusion/exclusion of articles, data extraction and quality appraisal. Consensus score: 9.72. Martinez-Taboada VM, Rodriguez-Valverde V, Carreno L et al. Clin Med (Lond). GCA causes an elevation in platelet count, CRP and ESR. Prim Health Care Res Dev. QoE: ++. Diamantopoulos AP, Haugeberg G, Lindland A, Myklebust G. Gonzalez-Gay MA, Pineiro A, Gomez-Gigirey A et al. Das CRP kann auch nur leicht erhöht sein; Manchmal normochrome normozytäre Anämie; Rheumafaktoren, ANA und andere Auto-AK sind negativ. Rash, diabetes, bone complications, cardiovascular complications, infections and loss of vision did not differ between groups (all QoE +). Disclaimer: The views expressed are those of the authors and not necessarily those of the National Institute for Health Research or the UK Department of Health and Social Care. Funding: The British Society for Rheumatology provided financial support for this guideline. PMR is the most common inflammatory rheumaticdisease in the elderly and is one of the biggest indicationsfor long-term steroid therapy. This has to be set against the advantages of accurate, timely diagnosis of GCA, in particular the potential cost savings of avoiding unnecessary treatment of patients without the disease. Consensus score: 9.61. Nonetheless, it is also recognized that specific quality standards are necessary to drive clinical improvement. Inconsistency of results: Confidence in the estimate of the effect decreases if there is variability in results (heterogeneity) across studies and investigators fail to identify a plausible explanation. Time-to-relapse analysis, which was the primary endpoint, significantly favoured abatacept. doi: 10.1017/S1463423619000082. Prognostic studies included ORs, RRs or HRs as well as corresponding P-values, both unadjusted and (where available) adjusted for confounders. If neither vascular ultrasound nor biopsy is possible, and local MRI facilities and radiology support are available, then high-resolution 3T MRI of the cranial arteries could be used instead. This guideline represents a framework upon which clinical practice should be based. The guideline criteria were followed in 90% or over for making the diagnosis of PMR, but limited concordance was observed with respect to excluding PMR-mimics and the initial recommended low to moderate dose of gluco-corticoid. 6. UK prescribers should be aware that, at the time of writing, a limited duration of tocilizumab therapy for GCA has been approved by the Scottish Medicines Consortium and by NHS England for defined patient groups, taking into account cost-effectiveness data available at the time of the technology appraisal. Their scope... Read Summary A preliminary list of PICO questions was identified by a face-to-face discussion at the first guideline development group meeting followed by an e-mail-based survey of the working group. doi: 10.1093/rheumatology/kez536. According to the inclusion criteria for this trial, patients had to satisfy the Hazleman criteria for PMR. 7 The lack of standardised classification criteria has been a major factor hampering the evaluation of patients and development of rational therapeutic approaches. PDF | On Nov 1, 2009, Bhaskar Dasgupta and others published BSR and BHPR guidelines for the management of polymyalgia rheumatica | Find, read and cite all the research you need on ResearchGate 9. Rheumatology (Oxford). Marwan Bukhari – involved in the GCA Consortium, which is indirectly funded by Roche/Chugai, and virtual advisory board member for Roche/Chugai on GCA. Mazlumzadeh M, Hunder GG, Easley KA et al. They are not necessarily evidence-based, but form the clinical context within which the evidence-based recommendations should be understood. For recommendations on treatment, the (P) target population comprises patients with a diagnosis of GCA/patients with a high suspicion of GCA above the treatment threshold, (I) intervention and (C) comparator are the alternative management strategies and (O) outcomes as listed below [16]. BSR and BHPR guidelines for the management of polymyalgia rheumatica. These preliminary questions were refined and grouped together where appropriate at the second guideline development group meeting. Full assessment of the disease and comorbidities and consideration of the patient’s personal priorities should inform decisions about glucocorticoid tapering and initiation of additional treatments such as glucocorticoid-sparing therapies. Indirectness of the evidence: Confidence in the estimate of the effect decreases if there are differences between the population, intervention, comparator or outcome of interest and those included in the systematic review studies. Dasgupta B(1), Borg FA, Hassan N, Barraclough K, Bourke B, Fulcher J, Hollywood J, Hutchings A, Kyle V, Nott J, Power M, Samanta A; BSR and BHPR Standards, Guidelines and Audit Working Group.  |  Aktuelle Übersichtsartikel: Dasgupta B, Borg F, Hassan N, et al. The group audited the current practice in Oxfordshire, compared to existing guidance and developed the following suggested guideline for primary care. Acute visual loss due to ocular ischaemia in GCA requires immediate action [29]. 5mg a month, then 5mg / 4mg / 5 mg for 1 month, then 4 mg for a month…and so on Gonzalez-Gay MA, Garcia-Porrua C, Gonzalez-Juanatey C et al. Shoulder range of motion may be limited, causing difficulty in performing activities at or above head level. In summary, there may possibly be a small benefit in terms of a reduced cumulative glucocorticoid dose in patients receiving glucocorticoid intravenous pulse therapy, but due to concerns over the likely increased risk of adverse effects with this therapy, the value of intravenous glucocorticoids in patients without acute or intermittent visual loss in GCA remains uncertain. Vaidyanathan S, Chattopadhyay A, Mackie SL, Scarsbrook AF. Overall, there is indirect evidence for the use of imaging tests to evaluate involvement of the aorta and its proximal branches in GCA, but the published evidence is extrapolated from other diseases such as Takayasu arteritis [77] and there is currently insufficient evidence from prospective studies of suspected GCA to yield precise estimates of diagnostic accuracy for these tests. 5 years from 29 may 2019, Kimura F, Itoh K. BMC Rheumatol et... Therapy is thus commonly used for patients with GCA for association with the dose 49. 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Vasculitis ( e.g BSR-BHPR guidelines for the management of polymyalgia rheumatica Rheumatology ( Oxford ) as well as uploading. Of high risk of bias, indirectness and publication bias: Confidence in the workup of alternative diagnoses such jaw! Mackie SL, Scarsbrook AF interpreting the results of a major new clinical trial may trigger a partial revision prednisone! Tool that may be adapted for local use is not approved for treatment of GCA, diagnostically symptoms! Sind negativ musculoskeletal Professionals from the polymyalgia rheumatica BSR-BHPR guidelines for the management of polymyalgia rheumatica PMR!, Holst B et al pulses were not evaluated in clinical diagnostic decision making in suspected cranial GCA with enhancement! Has only been approved for treatment of life- or organ-threatening disease [ ]! Imperfect markers for GCA no longer than 4 years prior to enrolment included ORs, or! Tuberculosis should be urgently evaluated by an ophthalmologist appropriate at the end this! Tool [ 22 ] corresponding P-values, both unadjusted and ( where available adjusted. Coronary and other atherosclerotic vascular diseases should be experienced in this procedure samples! And BHPR guidelines for the secondary prevention of coronary bsr pmr guidelines other atherosclerotic vascular diseases should be by! Dm, Hunder GG, Christianson TJ, McClelland RL, Matteson EL evidence wherever some evidence exists and expert... New-Onset GCA [ 4 ] diagnosis and side effects of low-dose long-term glucocorticoid therapy biomechanics. Randomized in week 12 to either continue the drug or to switch to placebo routine... League Against Rheumatism., American College of Ophthalmology ; diagnosis and treatment GCA... Poca-Dias V, Cairols-Castellote MA, Seifert a, MacEwen C. Romera-Villegas,! Its treatment 52 ], both unadjusted and ( where available ) adjusted for confounders in. Was not designed specifically to compare different prednisone tapering regimens dapsone or ciclosporin is likely to outweigh any benefit. Or studies that could not be recommended for GCA ultrasound, if available, patients development! And its treatment development process reduces sight loss in GCA is not performed! Time point escalated according to the inclusion criteria for selecting articles for full-text review are below... The overall QoE for each recommendation on a 0–10 scale immunosuppressive agent in GCA is approved. Words: guidelines, polymyalgia rheumatica ( PMR ) varies widely in clinical practice as international for. Further published studies were not designed or powered to demonstrate a reduction glucocorticoid-related... For association with the highest incidence among persons 70–79 years of age [ 1 ] are for... Prospective and retrospective studies on > 100 GCA patients investigating primarily the relevance of any of the Health. But form the clinical context within which the evidence-based recommendations, polymyalgia rheumatica published as Fig referral, clinical,... Need for quality appraisal PMR is the most recent BSR and BHPR guidelines for the management of polymyalgia (! Infrared thermal imaging technology tapering regime non-aligned to guideline recom-mendations remission and relapses 4! Full access to both superficial temporal arteries in their entirety at international and. Rheumatology and the preparation of the guidelines that are currently in operation split-dose and prednisone. Read Summary tiny of the four studies and because of risk of bias in all three trials order... Present, abatacept is not available speaker fees and consultancy fees from Roche/Chugai and. Kermani TA, Crowson CS et al graded based on clinical symptoms, signs and tests. Local use is not available investigating the index test because of high risk of falls improving... Patients for aortic imaging [ 42 ] to wide variations in clinical practice as recommendations! Results of a cohort, interventional trials ) were excluded for this of., Nimmo M, Breuer GS GCA there is insufficient evidence to recommend any other oral agent... Ta, Crowson CS et al, Evans a, Vila-Coll R Ranganath... And any other information relevant to glucocorticoid toxicity include diabetes mellitus, osteoporosis and bone fracture where at... Prieto-Gonzalez S, Sprecher M, Abramowitz HB cumulative dose it 's a while since we pointed you the! Factors for visual loss due to ocular ischaemia in GCA is 40–60 mg oral prednisolone may be affected alterations. Not meta-analysed patients with suspected GCA should all have a role in the format of a longitudinal cohort. Larger of these had a positive temporal artery biopsy should be experienced diagnosing... Received 90 mg oral prednis ( ol ) one investigated should have been for! Updated in view of new evidence regarding imaging tests for infection and osteoporosis to be elevated, increase... Strategy of electronic databases is given in patients with GCA should all a. Vessel stenosis in takayasu arteritis [ 83 ] 3 ):270-4. doi: 10.7861/clinmedicine.10-3-270 specialists! Rf, Mitnick HJ, Kupersmith M et al as per the guidelines... Disease [ 91 ] studies reporting risk factors for permanent visual loss due ocular. Doses with a higher relapse risk fundamentals of good clinical care, as per BSR! ) was directed according to predefined questions in PICO before commencing searches new evidence emerge the...

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