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Recommendations for early referral of individuals with suspected polymyalgia rheumatica: an initiative from the international giant cell arteritis and polymyalgia rheumatica study group
  1. Kresten Krarup Keller1,2,
  2. Chetan B Mukhtyar3,
  3. Andreas Wiggers Nielsen1,2,
  4. Andrea Katharina Hemmig4,
  5. Sarah Louise Mackie5,6,
  6. Sebastian Eduardo Sattui7,
  7. Ellen-Margrethe Hauge1,2,
  8. Anisha Dua8,
  9. Toby Helliwell9,
  10. Lorna Neill10,
  11. Daniel Blockmans11,12,
  12. Valérie Devauchelle-Pensec13,
  13. Eric Hayes1,
  14. Annett Jansen Venneboer14,
  15. Sara Monti15,
  16. Cristina Ponte16,17,
  17. Eugenio De Miguel18,
  18. Mark Matza19,
  19. Kenneth J Warrington20,
  20. Kevin Byram21,
  21. Kinanah Yaseen22,
  22. Christine Peoples7,
  23. Michael Putman23,
  24. Lindsay Lally24,
  25. Michael Finikiotis25,
  26. Simone Appenzeller26,
  27. Ugo Caramori27,
  28. Carlos Enrique Toro-Gutiérrez28,
  29. Elisabeth Backhouse29,
  30. María Camila Guerrero Oviedo30,
  31. Victor Román Pimentel-Quiroz31,32,
  32. Helen Isobel Keen33,
  33. Claire Elizabeth Owen34,35,
  34. Thomas Daikeler4,
  35. Annette de Thurah1,2,
  36. Wolfgang A Schmidt36,
  37. Elisabeth Brouwer14,
  38. Christian Dejaco37,38
  1. 1Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
  2. 2Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
  3. 3Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
  4. 4Clinic for Rheumatology, University Hospital, Basel, Switzerland
  5. 5Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
  6. 6Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  7. 7Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  8. 8Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  9. 9School of Medicine, University of Staffordshire, Stafford, UK
  10. 10Patient Charity Polymyalgia Rheumatica and Giant Cell Arteritis Scotland, Dundee, UK
  11. 11Clinical Department of General Internal Medicine Department, Research Department of Microbiology and Immunology, Laboratory of Clinical Infectious and Inflammatory Disorders, University Hospitals Leuven, Leuven, Belgium
  12. 12Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
  13. 13Rheumatology, Brest University and La Cavale Blanche Hospital, Brest, France
  14. 14Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
  15. 15Rheumatology, Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia, Italy
  16. 16Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
  17. 17Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
  18. 18Hospital Universitario La Paz, Madrid, Spain
  19. 19Massachusetts General Hospital, Boston, Massachusetts, USA
  20. 20Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
  21. 21Vanderbilt Rheumatology, Vanderbilt Health, Nashville, Tennessee, USA
  22. 22Orthopedic and Rheumatologic Insitute, Cleveland Clinic, Cleveland, Ohio, USA
  23. 23Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  24. 24Hospital for Special Surgery, New York, New York, USA
  25. 25University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
  26. 26Departamento de Clínica Médica, Facultade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
  27. 27Department of Public Health, State University of Campinas, Campinas, Brazil
  28. 28Reference Center in Osteoporosis, Rheumatology & Dermatology, Pontificia Universidad Javeriana Cali Facultad de Ciencias de la Salud, Cali, Colombia
  29. 29Perth, Perth, Western Australia, Australia
  30. 30Clínica Imbanaco, Cali, Colombia
  31. 31Rheumatology, Hospital Nivel IV Guillermo Almenara Irigoyen, Lima, Peru
  32. 32School of Medicine, Universidad Científica del Sur, Lima, Peru
  33. 33Medicine and Pharmacology, UWA, Murdoch, Perth, Australia
  34. 34Rheumatology, Austin Health, Heidelberg, Victoria, Australia
  35. 35Medicine, University of Melbourne, Melbourne, Victoria, Australia
  36. 36Rheumatology, Immanuel-Krankenhaus GmbH, Berlin, Germany
  37. 37Rheumatology, Brunico Hospital, Brunico, Italy
  38. 38Rheumatology, Medical University of Graz, Graz, Austria
  1. Correspondence to Dr Kresten Krarup Keller, Department of Rheumatology, Aarhus University Hospital, Aarhus, 8200, Denmark; krekel{at}


Objective To develop international consensus-based recommendations for early referral of individuals with suspected polymyalgia rheumatica (PMR).

Methods A task force including 29 rheumatologists/internists, 4 general practitioners, 4 patients and a healthcare professional emerged from the international giant cell arteritis and PMR study group. The task force supplied clinical questions, subsequently transformed into Population, Intervention, Comparator, Outcome format. A systematic literature review was conducted followed by online meetings to formulate and vote on final recommendations. Levels of evidence (LOE) (1–5 scale) and agreement (LOA) (0–10 scale) were evaluated.

Results Two overarching principles and five recommendations were developed. LOE was 4–5 and LOA ranged between 8.5 and 9.7. The recommendations suggest that (1) each individual with suspected or recently diagnosed PMR should be considered for specialist evaluation, (2) before referring an individual with suspected PMR to specialist care, a thorough history and clinical examination should be performed and preferably complemented with urgent basic laboratory investigations, (3) individuals with suspected PMR with severe symptoms should be referred for specialist evaluation using rapid access strategies, (4) in individuals with suspected PMR who are referred via rapid access, the commencement of glucocorticoid therapy should be deferred until after specialist evaluation and (5) individuals diagnosed with PMR in specialist care with a good initial response to glucocorticoids and a low risk of glucocorticoid related adverse events can be managed in primary care.

Conclusions These are the first international recommendations for referral of individuals with suspected PMR, which complement the European Alliance of Associations for Rheumatology/American College of Rheumatology management guidelines for established PMR.

  • Polymyalgia Rheumatica
  • Vasculitis
  • Giant Cell Arteritis

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  • Handling editor Josef S Smolen

  • Twitter @cmukhtyar, @Sarah_L_Mackie, @SattuiSEMD, @anisha_dua, @cristinadbponte, @VictorioPQ, @drceowen

  • Correction notice This article has been corrected since it published Online First. An affiliation has been added for the author Victor R Pimentel-Quiroz.

  • Contributors All task force members were involved in preparing the project. KKK drafted the first version of the manuscript. The steering group members revised the manuscript before it was sent to the task force. All task force members made edits and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. KKK has received funding for research in PMR from Central Denmark Region and Aarhus University Hospital.

  • Disclaimer The views expressed in this article are those of the authors and not necessarily those of the NIHR, the NIHR Leeds Biomedical Research Centre, the National Health Service or the UK Department of Health and Social Care.

  • Competing interests KKK: Research grants from Independent Research Fund Denmark, Danish Rheumatic Association and Central Denmark Region unrelated to this project. SES: Research grants from Rheumatology Research Foundation, Bristol Myers Squibb Foundation. Clinical trial support from AstraZeneca, GlaxoSmithKline; Consulting fees from Sanofi (funds toward research support); Data Safety Monitoring Board on MINT trial, Advisory Board for Sanofi (funds toward research support). E-MH: Has received grants unrelated to this manuscript from Novo Nordic Foundation, Roche, Novartis; Personal fees from AbbVie, Sanofi, SOBI, Merck Sharp & Dohme and Union Chimique Belge. AD: Consulting fees from Sanofi; Participation on a Data Safety Monitoring Board or Advisory Board for Sanofi; Board member Vasculitis Foundation. LN: Has received Honorarium from Abbvie; Trustee of the charity PMR-GCA Scotland. SM: Consulting fees from Astrazeneca; Honoraria from Vifor. KJW: Grants from Eli Lilly, Kiniksa, BMS; Consulting fees from Amgen, Sanofi. Honoraria from Amgen. CP: Consulting fee from Pfizer. MP: Consulting fee from Novartis; Clinical trial participant for Abbvie, Amgen, AstraZeneca. HIK: Honoraria from Roche, eTherapeutic Guidelines Australia; Board member Australian Rheumatology Association; Clinical trials for Roche, Abbvie, Sun, Emerald, Novartis, Biogen, Sanofi, Syneos. CEO: Consultancy for Abbvie; Speaking honoraria from Abbvie, Janssen, Novartis and Roche; Advisory board for Abbvie. WAS: Has received honoraria from Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, Sanofi ; Support for attending meetings/travel from Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, Sanofi; Participated in advisory board from Abbvie, GlaxoSmithKline, Novartis, Sanofi; Principle investigator of phases 2 and 3 studies sponsored by Abbvie, GlaxoSmithKlinie, Novartis and Sanofi. EBrouwer: As an employee of the UMCG received a speaker fee for a talk on GCA at a post EULAR symposium in the Netherlands in 2023 which was paid to the UMCG; As an employee of the UMCG received grants from the Dutch Arthritis Society DAS and the EU/EFPIA/Innovative Medicines Initiative 2 Joint Undertaking Immune-Image grant no 831514 which were paid to the UMCG. SM: Consultancy on behalf of her institution for Roche/Chugai, Sanofi, AbbVie, AstraZeneca, Pfizer; Investigator on clinical trials for Sanofi, GSK, Sparrow; speaking/lecturing on behalf of her institution for Roche/Chugai, Vifor, Pfizer, UCB, Novartis and AbbVie; chief investigator on STERLING-PMR trial, funded by NIHR; patron of the charity PMRGCAuk. No personal remuneration was received for any of the above activities. Support from Roche/Chugai to attend EULAR2019 in person and from Pfizer to attend ACR Convergence 2021 virtually. SM is supported in part by the NIHR Leeds Biomedical Research Centre. VD-P has received honorarium from Abbvie, Chugai, Novartis, BMS, Support for attending meetings/travel from Novartis; Participated in advisory borad from Abbvie, Novartis. All other authors have no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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