Treatment of PMR is subject to wide variations among clinicians as it may be managed in primary or secondary care by general practitioners, rheumatologists and non-rheumatologist. Particularly the initial corticosteroid dose, strategies for tapering, duration of treatment and the use of disease modifying anti-rheumatic drugs significantly differ among physicians caring for PMR patients. ACR/EULAR endorsed recommendations for PMR will have a significant impact on clinical decision making, reduce practice variations and stimulate further research in areas where there is currently lack of adequate evidence.
The broad objective of these guidelines is to provide user-friendly, evidence-based recommendations that offer best clinical advice for the short and long term management of patients with a diagnosis of PMR in a primary and secondary care setting. We have also developed recommendations on the use of routinely available prognostic factors informing clinical decisions of physicians caring for PMR patients. These recommendations aim at improved outcome of PMR patients and are based on best clinical evidence, alongside expert consensus. The recommendations also take into account patient choice and informed decision-making.
The target population of these guidelines are patients meeting the case definition of the EULAR ACR PMR provisional classification criteria (1). The guidelines are limited to patients with PMR. Primary, secondary and tertiary care physicians [i.e. General practitioners (GPs), specialists in general (internal) medicine and rheumatologists are the target users of these guidelines.
The guidelines affirm over-arching principles for the care of PMR. These include the adoption of a safe and specific approach to ascertaining the PMR case definition. The clinical evaluation should be directed towards exclusion of relevant mimicking conditions. There should be the documentation of a laboratory dataset before prescribing glucocorticoids. This will help exclude mimicking conditions and establish a baseline for monitoring glucocorticoid therapy. This should include Rheumatoid Factor and/or ACPA, CRP and/or ESR. Risk factors for steroid related side-effects, comorbidities and other relevant medications; Risk factors for relapse/prolonged therapy; Consideration of specialist referral for atypical presentation, high risk for side effects, relapse/prolonged therapy- should form part of the initial evaluation and subsequent monitoring. Patients should have access to education focusing on disease, medications; impact of PMR and treatment (including co-morbidities and disease predictors) and individually tailored exercises.
Patients should have an individualised PMR-management plan with individualised choice of initial glucocorticoid dose and subsequent tapering of glucocorticoids in PMR.
The guidelines make recommendations on twelve PICO questions based on GRADE appraisal of PMR data, external evidence, benefits/side effects, as well as values and preferences of clinicians and patients. These include the initial dose of glucocorticoids, tapering of the glucocorticoid dose, role of early disease modification with methotrexate in certain sub groups, role of intramuscular glucocorticoids, role of NSAIDs and biological agents. The guidelines also make recommendations on a future research agenda for PMR.
Disclosure of Interest None declared