Background/Purpose: Polymyalgia rheumatica (PMR) is the second-most common inflammatory rheumatic disease but there remains variation amongst rheumatologists in approaches to diagnosis and management. This study aimed to evaluate the perceptions and approaches to PMR in a cohort of Australian rheumatologists.

Methods: Rheumatologist and trainee members of the Australian Rheumatology Association were invited via email to participate in a survey that explored opinions and experience around PMR diagnosis and management.

Results: Responses were received from 79 clinicians, of which 57 (72%) answered the survey to completion. 51% were female, and clinical experience varied from 0-10 years (40%) to over 20 years (26%), with a mix of public hospital work (75%) and private practice (58%). 75% of respondents managed at least one patient with PMR every fortnight.

Regarding PMR presentation and diagnosis, 23% believed that bilateral shoulder involvement is necessary to make a diagnosis of PMR, while 76% believed it occurs “most of the time”. 37% believed elevated inflammatory markers are necessary for diagnosis, while 59% acknowledged that inflammatory markers may be normal although an uncommon occurrence. 13% regarded peripheral involvement as preclusion of a PMR diagnosis. Imaging was largely deemed useful in the setting of diagnostic uncertainty (72%).

Regarding treatment, there was a consensus for starting prednisolone at 15 mg (83%) with 75% favoring a 12-month steroid wean. 98% reported having prescribed a steroid-sparing drug in PMR before, with almost half using this in 25-50% of PMR patients. The most common indications for initiating a steroid-sparing drug were first relapse (29%) and second or later relapse (49%), although most would consider it in patients at high risk of steroid side effects (79%). Standard choices included methotrexate (98%), leflunomide (27%), tocilizumab (13%), and hydroxychloroquine (10%). The majority agreed there is no strong evidence to support the use of methotrexate (86%) or leflunomide (95%).

Regarding monitoring and progress, the most common issues to arise during the disease course included steroid side effects (90%), pain (87%), stiffness (82%), fatigue (79%), and impact on physical function (75%). 48% recognized two distinct patient populations – those who have self-limiting disease which remits within 24 months and those who require lifelong low-dose prednisolone.

Conclusion: Australian rheumatologists had diverse opinions around the diagnostic features of PMR and the role of imaging. Many acknowledged that a diagnosis of PMR might be appropriate even in the absence of bilateral shoulder involvement and abnormal inflammatory markers in contrast to the 2012 EULAR/ACR provisional classification criteria. The majority had initiated a steroid-sparing drug in a PMR patient despite the lacking evidence base. The need for lifelong treatment in some patients was also recognized. Substantial variation existed in other areas of practice.

These findings challenge the classic paradigm of PMR as a self-limiting disease managed with steroid monotherapy, emphasizing the need for standardization of practice and further research into consistent diagnosis and treatment.

« Back to ACR Convergence 2023

ACR Meeting Abstracts - https://acrabstracts.org/abstract/variations-in-approach-to-the-diagnosis-and-management-of-polymyalgia-rheumatica-among-australian-rheumatologists/