J Korean Med Sci.  2012 Jan;27(1):22-26. 10.3346/jkms.2012.27.1.22.

Induction of Remission is Difficult due to Frequent Relapse during Tapering Steroids in Korean Patients with Polymyalgia Rheumatica

• Kim HA
• Lee J
• Ha YJ
• Kim SH
• Lee CH
• Choi HJ
• Baek HJ
• Lim MJ
• Park W
• Choi S
• Hong YS
• Lee YH
• Koh BR
• Suh CH

• KMID: 1792974
• DOI: http://doi.org/10.3346/jkms.2012.27.1.22

Abstract

Polymyalgia rheumatica is an inflammatory disease affecting elderly and involving the shoulder and pelvic girdles. No epidemiological study of polymyalgia rheumatica was conducted in Korea. We retrospectively evaluated patients with polymyalgia rheumatica followed up at the rheumatology clinics of 10 tertiary hospitals. In total 51 patients, 36 patients (70.6%) were female. Age at disease onset was 67.4 yr. Twenty-three patients (45.1%) developed polymyalgia rheumatica in winter. Shoulder girdle ache was observed in 45 patients (90%) and elevated erythrocyte sedimentation rate (> 40 mm/h) in 49 patients (96.1%). Initial steroid dose was 23.3 mg/d prednisolone equivalent. Time to normal erythrocyte sedimentation rate was 4.1 months. Only 8 patients (15.7%) achieved remission. Among 41 patients followed up, 28 patients (68.3%) had flare at least once. Number of flares was 1.5 +/- 1.6. The frequency of flare was significantly lower in patients with remission (P = 0.02). In Korea, polymyalgia rheumatica commonly develops during winter. Initial response to steroid is fairly good, but the prognosis is not benign because remission is rare with frequent relapse requiring long-term steroid treatment.

Keyword

Polymyalgia Rheumatica; Symptoms; Treatment; Steroids; Remission; Prognosis

MeSH Terms

Aged
Aged, 80 and over
Anti-Inflammatory Agents/administration & dosage/*therapeutic use
Blood Sedimentation
Cohort Studies
Female
Humans
Male
Middle Aged
Polymyalgia Rheumatica/*drug therapy/epidemiology
Prognosis
Recurrence
Republic of Korea/epidemiology
Retrospective Studies
Seasons
Steroids/administration & dosage/*therapeutic use

Reference

1. Cimmino MA, Zaccaria A. Epidemiology of polymyalgia rheumatica. Clin Exp Rheumatol. 2000. 18:S9–S11.

2. Chuang TY, Hunder GG, Ilstrup DM, Kurland LT. Polymyalgia rheumatica: a 10-year epidemiologic and clinical study. Ann Intern Med. 1982. 97:672–680.

3. Michet CJ, Matteson EL. Polymyalgia rheumatica. BMJ. 2008. 336:765–769.

4. Smeeth L, Cook C, Hall AJ. Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990-2001. Ann Rheum Dis. 2006. 65:1093–1098.

5. Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008. 372:234–245.

6. Bird HA, Esselinckx W, Dixon AS, Mowat AG, Wood PH. An evaluation of criteria for polymyalgia rheumatica. Ann Rheum Dis. 1979. 38:434–439.

7. Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum. 1984. 13:322–328.

8. Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica. Best Pract Res Clin Rheumatol. 2004. 18:705–722.

9. van der Veen MJ, Dinant HJ, van Booma-Frankfort C, van Albada-Kuipers GA, Bijlsma JW. Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis? Ann Rheum Dis. 1996. 55:218–223.

10. Ferraccioli G, Salaffi F, De Vita S, Casatta L, Bartoli E. Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol. 1996. 23:624–628.

11. Caporali R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, Montecucco C. Systemic Vasculitis Study Group of the Italian Society for Rheumatology. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2004. 141:493–500.

12. Salvarani C, Cantini F, Niccoli L, Catanoso MG, Macchioni P, Pulsatelli L, Padula A, Olivieri I, Boiardi L. Treatment of refractory polymyalgia rheumatica with infliximab: a pilot study. J Rheumatol. 2003. 30:760–763.

13. Migliore A, Massafra U, Carloni E, Padalino C, Martin S, Lasaracina F, Dibiase N, Alimonti A, Granata M. TNF-alpha blockade induce clinical remission in patients affected by polymyalgia rheumatica associated to diabetes mellitus and/or osteoporosis: a seven cases report. Eur Rev Med Pharmacol Sci. 2005. 9:373–378.

14. Catanoso MG, Macchioni P, Boiardi L, Pipitone N, Salvarani C. Treatment of refractory polymyalgia rheumatica with etanercept: an open pilot study. Arthritis Rheum. 2007. 57:1514–1519.

15. Mori S, Koga Y, Ito K. Clinical characteristics of polymyalgia rheumatica in Japanese patients: evidence of synovitis and extracapsular inflammatory changes by fat suppression magnetic resonance imaging. Mod Rheumatol. 2007. 17:369–375.

16. Mackie SL, Hensor EM, Haugeberg G, Bhakta B, Pease CT. Can the prognosis of polymyalgia rheumatica be predicted at disease onset? Results from a 5-year prospective study. Rheumatology (Oxford). 2010. 49:716–722.

17. Li WL, Lo Y, Leung MH, Wong WS, Mok MY. The clinical course of polymyalgia rheumatica in Chinese. Clin Rheumatol. 2010. 29:199–203.

18. Pease CT, Haugeberg G, Montague B, Hensor EM, Bhakta BB, Thomson W, Ollier WE, Morgan AW. Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study. Rheumatology (Oxford). 2009. 48:123–127.

19. Salvarani C, Cantini F, Macchioni P, Olivieri I, Niccoli L, Padula A, Boiardi L. Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 1998. 41:1221–1226.

20. Hutchings A, Hollywood J, Lamping DL, Pease CT, Chakravarty K, Silverman B, Choy EH, Scott DG, Hazleman BL, Bourke B, Gendi N, Dasgupta B. Clinical outcomes, quality of life, and diagnostic uncertainty in the first year of polymyalgia rheumatica. Arthritis Rheum. 2007. 57:803–809.

21. Bird HA, Leeb BF, Montecucco CM, Misiuniene N, Nesher G, Pai S, Pease C, Rovensky J, Rozman B. A comparison of the sensitivity of diagnostic criteria for polymyalgia rheumatica. Ann Rheum Dis. 2005. 64:626–629.

22. Kobayashi S, Yano T, Matsumoto Y, Numano F, Nobuyuki N, Yasuda K, Yutani C, Nakayama T, Tamakoshi A, Kawamura T, Ohno Y, Inaba Y, Hashimoto H. Clinical and epidemiologic analysis of giant cell (temporal) arteritis from a nationwide survey in 1998 in Japan: the first gonvernment-supported nationwide survey. Arthritis Rheum. 2003. 49:594–598.

23. Mertens JC, Willemsen G, Van Saase JL, Bolk JH, Dijkmans BA. Polymyalgia rheumatica and temporal arteritis: a retrospective study of 111 patients. Clin Rheumatol. 1995. 14:650–655.

24. Cimmino MA, Caporali R, Montecucco CM, Rovida S, Baratelli E, Broggini M. A seasonal pattern in the onset of polymyalgia rheumatica. Ann Rheum Dis. 1990. 49:521–523.

25. Petursdottir V, Johansson H, Nordborg E, Nordborg C. The epidemiology of biopsy-positive giant cell arteritis: special reference to cyclic fluctuations. Rheumatology (Oxford). 1999. 38:1208–1212.

26. Peris P. Polymyalgia rheumatica is not seasonal in pattern and is unrelated to parvovirus b19 infection. J Rheumatol. 2003. 30:2624–2626.

27. Narváez J, Clavaguera MT, Nolla-Solé JM, Valverde-Garcia J, Roig-Escofet D. Lack of association between infection and onset of polymyalgia rheumatica. J Rheumatol. 2000. 27:953–957.

28. Kremers HM, Reinalda MS, Crowson CS, Zinsmeister AR, Hunder GG, Gabriel SE. Relapse in a population based cohort of patients with polymyalgia rheumatica. J Rheumatol. 2005. 32:65–73.

29. Salvarani C, Macchioni P, Manzini C, Paolazzi G, Trotta A, Manganelli P, Cimmino M, Gerli R, Catanoso MG, Boiardi L, Cantini F, Klersy C, Hunder GG. Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial. Ann Intern Med. 2007. 146:631–639.

30. Salvarani C, Cantini F, Niccoli L, Macchioni P, Consonni D, Bajocchi G, Vinceti M, Catanoso MG, Pulsatelli L, Meliconi R, Boiardi L. Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 2005. 53:33–38.