Session Information
Date: Tuesday, October 23, 2018
Title: Vasculitis Poster III: Immunosuppressive Therapy in Giant Cell Arteritis and Polymyalgia Rheumatica
Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose:
Polymyalgia rheumatica (PMR) is a frequent inflammatory condition in patients over 50 years old. Nearly 60% of patients experience relapses of the symptoms during steroids tapering and steroids dependency is frequent. There is a need to find other therapeutic options to avoid the risks of long term steroid treatment. Methotrexate (MTX) use in PMR has been studied with contradictory results regarding reduction of relapses.
Our objective was to evaluate the efficacy of MTX to reduce relapses and recurrences in patients with PMR.
Methods:
This is an observational longitudinal cohort study. We included 94 consecutive patients with PMR fulfilling EULAR/ACR 2012 criteria. Clinical symptoms, laboratory results, treatment received and disease course information were extracted from the medical records.
Patients were assigned to 3 groups according to the treatment prescribed by the treating physician. Group 1: treated with steroids alone, group 2: treated with steroids initially and MTX following a relapse or recurrence and group 3: treated with steroids and MTX from diagnosis.
Definitions:
- Relapse: recurrence of symptoms and an increase of erythrocyte sedimentation rate (ESR) or C reactive protein (CRP) in patients still receiving steroids.
- Remission: time of discontinuing prednisone.
- Recurrence: recurrence of the original symptoms and an increase of ESR or CRP after discontinuing prednisone.
We studied predictors of relapse in the total population. To evaluate MTX effect, patients from group 2 were analyzed comparing outcomes during the first period with corticosteroids alone with the second period with steroids and MTX.
Results:
Ninety four patients were included, 77.6% women, mean age 75.6 years old (SD 8.1). The median time of follow up was 21.3 months (IQR 11.7-56.2).
Patients were assigned to one of 3 groups according to their treatment: 53 (56.4%) were treated only with steroids (group 1), 33 (35.1%) received initially steroids and later on MTX (group 2) and 8 (8.5 %) had steroids and MTX from diagnosis (group 3). Table 1 shows a comparison between groups.
We found a tendency of ESR to predict relapses (p 0.07) in the total population.
In group 2, we identified 35 relapses during the period of treatment with steroids alone and only 8 relapses during the period of combined treatment (p 0.0001). MTX reduced the dose of corticosteroids used and reduced the time to remission in this group of patients (Table 2).
Table 1
|
GROUP 1 |
GROUP 2 |
GROUP 3 |
|
|
N |
53 |
33 |
8 |
|
One relapse, n (%) |
12 (22.6) |
28 (84.8) |
4 (50) |
|
More than 1 relapse, n (%) |
3 (5.6) |
11 (33.3) |
2 (25) |
|
Time to the first relapse, months, median (IQR) |
9.2 (6.7-10.7) |
8.6 (6-14.9) |
21.5 (9.6-92.8) |
|
Remission, n (%) |
20 (37.7) |
14 (42.4) |
3 (37.5) |
|
Time to remission, m (IQR) |
12.9 (11.8-21.6) |
21.2 (15-25.2) |
13.3 (12.4-99.8) |
|
Duration of remission, m (SD) |
1.8 (0-15.2) |
6.6 (2.8-17.6) |
19.5 (4.4-40.5) |
|
Recurrence, n (%) |
4 (7.5) |
11 (33.3) |
0 (0) |
|
Total dose of steroids, g, mean (SD) |
3.7 (4.8) |
5.6 (3.3) |
12 (14.6) |
Table 2
|
pre MTX |
post MTX |
p |
|
|
Relapses, n |
35 |
8 |
0.0001 |
|
Time to first relapse, months, median (ICR) |
13.2 (6.4-16.8) |
9.2 (6.2-17.4) |
0.12 |
|
Time free of relapse, months, median (ICR) |
8.6 (5.3-14.9) |
7.5 (4.6-17.4) |
0.25 |
|
Dose of steroids at first relapse, mg/day, mean (SD) |
5.1 (2.3) |
3 (1.5) |
0.02 |
|
Remission, n |
7 |
9 |
0.73 |
|
Time to remission, months, median (ICR) |
22.9 (18.1-30.1) |
8.7 (7-12.2) |
0.01 |
|
Duration of remission, months, mean (SD) |
14.7 (17.4) |
13.9(20.9) |
0.53 |
|
Recurrences, n |
7 |
4 |
0.36 |
Conclusion:
The use of MTX in PMR patients who already had a relapse reduces the number of future relapses and reduced the time to achieve remission. Starting MTX allowed a reduction of corticosteroids dose.
To cite this abstract in AMA style:
de la Torre ML, Rodriguez A, Cosatti MA, Pisoni CN. Utility of Methotrexate in Polymyalgia Rheumatica [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/utility-of-methotrexate-in-polymyalgia-rheumatica/. Accessed .ACR Meeting Abstracts - https://acrabstracts.org/abstract/utility-of-methotrexate-in-polymyalgia-rheumatica/