We included randomized controlled trials (RCTs) involving >20 patients with GCA. Eleven of 31 of these had a positive temporal artery biopsy. PDF | On Nov 1, 2009, Bhaskar Dasgupta and others published BSR and BHPR guidelines for the management of polymyalgia rheumatica | Find, read and cite all the research you need on ResearchGate In GCA there is inflammation within the walls of medium and large-sized arteries, with associated intimal hyperplasia [3]. the BSR and BHPR Standards, Guidelines and Audit Working Group Key words: Guidelines, Polymyalgia rheumatica, Diagnosis, Treatment, Corticosteroid. BSR and BHPR Guidelines for the management of giant cell arteritis Bhaskar Dasgupta1, Frances A. Borg1, Nada Hassan1, Leslie Alexander1, ... with PMR, it represents one of the commonest indications for long-term glucocorticosteroid therapy in the commu-nity [1, 2]. PMR should be suspected in a person older than 50 years of age presenting with: Bilateral shoulder and/or pelvic girdle aching lasting more than 2 weeks. Lorna Neil – chair of PMR-GCA Scotland and patient representative for the EULAR working group on imaging in LVV. Justin C. Mason – received speaker fees and consultancy fees from Roche/Chugai. British Society for Rheumatology (BSR) Publication date: 01 November 2009. We further excluded studies that did not report the result of a statistical test for association with the outcome. Moderate QoE (+++) from one study [90] suggested a reduction of the cumulative glucocorticoid dose at week 78 {median cumulative glucocorticoid dose 5636 mg [interquartile range (IQR) 4050–6690]} in the group that received 3 days of intravenous methylprednisolone compared with 7860 mg (IQR 7373–9005) in the control group. In the absence of clinical features of cranial GCA, temporal artery biopsy can still be positive, but imaging of the extracranial large vessels may be considered instead of, or in addition to, temporal artery biopsy. Patients should be advised of potential symptoms of glucocorticoid withdrawal, although these are uncommon in practice. Patients without a history of chicken pox (varicella zoster virus infection) should be advised to avoid close contact with people who have chickenpox or shingles and to seek urgent medical advice if they have been exposed. Imprecision: Confidence in the estimate of the effect decreases if the systematic review includes relatively few patients and few events and thus has wide confidence intervals and/or the extremes of the confidence intervals are close to the null effect. Overall, there is indirect evidence for the use of imaging tests to evaluate involvement of the aorta and its proximal branches in GCA, but the published evidence is extrapolated from other diseases such as Takayasu arteritis [77] and there is currently insufficient evidence from prospective studies of suspected GCA to yield precise estimates of diagnostic accuracy for these tests. Consensus score: 9.00. However, this must be set against the potential cost savings arising from a reduction in cumulative glucocorticoid doses and thereby a reduction in glucocorticoid-associated adverse events. The ACR criteria for GCA, which are not suitable for clinical diagnosis, served as the reference standard in both studies. Polymyalgia rheumatica (PMR) is a common inflammatory condition that generally affects people over the age of 50 years. However, there was an increased risk of treatment discontinuation due to toxicity [RR 13.00 (CI 1.78, 95.1), QoE ++]. Plasma viscosity can be used where ESR is unavailable. Each outcome was graded based on its relative importance for clinical decision making on a 1–9 point scale [15]. Regarding efficacy data, the two larger trials [88, 98] could be pooled but the smallest trial [99] was considered separately because it substantially differed from the two other trials regarding design (lower MTX dose used, initiation of therapy upon reduction of glucocorticoid dose) and quality. A UK National Institute for Health and Care Excellence (NICE) technology appraisal has been conducted with regard to tocilizumab therapy for GCA [113], which has the potential to significantly increase the direct costs of drug treatment of GCA. 8. Your comment will be reviewed and published at the journal's discretion. Aims: The aim of these guidelines is a safe and specific diagnostic process for polymyalgia rheumatica (PMR), using continued assessment, and discouragement of hasty initial treatment. In practice, constraints of the healthcare system may create challenges to widespread implementation of this guideline. There is also experience with CTA for accurate assessment of luminal diameter for large vessel stenosis in Takayasu arteritis [83]. Gonzalez-Gay MA, Blanco R, Rodriguez-Valverde V et al. Were all characteristics of patients known or suspected to affect the outcome recorded? Clinical trials have not been conducted in patients with acute ocular ischaemia, but observational data indicate that the vast majority of visual loss in GCA occurs before initiation of glucocorticoid therapy. The British Society for Rheumatology and the British Health Professionals in Rheumatology have recently published guidelines on management of PMR. Jakobsson K, Jacobsson L, Mohammad AJ et al. The potential toxicity of dapsone or ciclosporin is likely to outweigh any possible benefit and their use is not recommended. Therapy-Related Imaging Findings in Patients with Sarcoma. However, this should be adapted for the individual patient. 2019 Dec 1;58(Suppl 7):vii29-vii39. if clinical features of GCA - treat as GCA (usually oral prednisolone 40-60mg daily) (see GCA guideline) if clinical features of PMR - increase prednisolone to previous higher dose. Treatment recommendations have been tailored to these subgroups given that the trade-off between benefit and harm, values and preferences as well as consideration regarding resource use may vary according to the presence or absence of risk factors. Takayasu arteritis and other forms of vasculitis (e.g. Pooling of the two larger studies indicated moderate QoE (+++) that MTX reduced the proportion with relapse at 12–24 months [RR 3.20 (95% CI 1.49, 6.87)] [88, 98]; the smallest trial showed no difference in relapse between the MTX and placebo groups (QoE +) [99]. Dasgupta B, Matteson EL, Maradit-Kremers H. Management guidelines and outcome measures in polymyalgia rheumatica (PMR). Abstract. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? Peter Lanyon – former president of the BSR (April 2016–18) and chair of the Rare Autoimmune Rheumatic Disease Alliance (RAIRDA). The QoE was ++; downgrading was performed for risk of bias in all three studies and for inconsistency. 4. Ramsay M, ed. Jack Cush, MD; Feb 17, 2020 10:01 am NICE has commissioned an update to the 2010 British Society for Rheumatology (BSR) guideline for the management of giant cell arteritis (GCA), and proposed a total of 19 recommendations for the diagnosis and treatment of GCA. QoE: +. Exposure to tuberculosis should be discussed and screened according to national guidelines [50]. Anaemia was more common in the dapsone group compared with the control group [RR 8.89 (CI 1.27, 61.99), QoE ++] and the dapsone group had two cases of agranulocytosis. Other issues of relevance to cranial vascular MRI are low availability of high-resolution 3T MRI equipment and expertise, higher costs and possible adverse effects of contrast agents. 11. No significant difference was found between the groups at 2 months concerning relapse rate (QoE +) or visual loss (QoE ++). Active GCA (see BSR Guidelines for GCA) Inflammatory: RA other arthropathies SLE, myopathies, other CTDs Non-inflammatory: Local shoulder and hip conditions Fibromyalgia/pain syndromes Step 3 Low-dose steroids Prednisolone 15–20 mg daily Clinical response in 1 week At least 70% global improvement Lab. A proposed list of clinical assessments that could be carried out at or near diagnosis of GCA, Features of GCA relevant to prognosis: fever, sweats or weight loss; ischaemic manifestations (jaw claudication, tongue claudication), Signs and symptoms indicating involvement of extracranial arteries, e.g. We included prospective and retrospective studies on >100 GCA patients investigating primarily the relevance of any of the prognostic factors of interest. A possible approach to using rapid-access vascular ultrasound to assist in clinical diagnostic decision making in suspected cranial GCA. guidance, including providing patients with information on coronavirus. Rash, diabetes, bone complications, cardiovascular complications, infections and loss of vision did not differ between groups (all QoE +). In contrast to the 2010 guideline, where the authors outlined that imaging techniques are promising for diagnosis and monitoring of GCA [10], in this guideline there is now sufficient evidence, taken together, to state that all patients with GCA should have at least one confirmatory diagnostic test, which could be either temporal artery biopsy or temporal and axillary artery ultrasound. Tumor-like Lesions of Bone and Soft Tissues and Imaging Tips for Differential Diagnosis. Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. Aiello PD, Trautmann JC, McPhee TJ, Kunselman AR, Hunder GG. The guideline criteria were followed in 90% or over for making the diagnosis of PMR, but limited concordance was observed with respect to excluding PMR-mimics and the initial recommended low to moderate dose of gluco-corticoid. Compared to symptoms of non … Alfred Mahr – received honoraria for advisory board meetings and lectures from Chugai Pharma France. In an international multicentre observational study reporting data from 433 GCA patients from 26 countries, 34 patients developed complete loss of vision in one or both eyes at 6 months. However, temporal artery biopsy and ultrasound differ in their positive and negative likelihood ratios for GCA, with biopsy having relatively greater ‘rule-in’ value and ultrasound having relatively greater ‘rule-out’ value (Supplementary Files, available at Rheumatology online). Polymyalgia Rheumatica is primarily managed with steroids, NSAIDs and DMARDs, I have seen a few of these patients attend Physio for restoration of function (range of motion and strength) or for bone protection due to the risks of the steroids. The guideline was developed in accordance with the BSR Guidelines Protocol. secondary large vessel vasculitis) are not covered by this guideline. CTA can reveal wall thickening with contrast enhancement in biopsy-proven GCA [82]. Each follow-up visit should include at least a full history, targeted physical examination and measurement of at least a full blood count, ESR and/or CRP, plus follow-up of any abnormalities relevant to the individual patient as well as drug-specific screening for toxicity. Six studies (500 patients with suspected GCA, of whom 268 were finally diagnosed with GCA) compared cranial artery MRI (vessel wall oedema and contrast enhancement) with clinical diagnosis, giving a pooled sensitivity of 75% (95% CI 69, 80) and a pooled specificity of 89% (95% CI 84, 93) [71–76]. A multicenter study of 549 patients. There are difficulties in There are no clinical trials comparing different initial oral glucocorticoid doses for GCA. No differences were found between pulse therapy and control groups as regards discontinuation of glucocorticoids at 12 months (QoE +) [87], patients with at least one relapse at 78 weeks and drug-free remission at 78 weeks (both with QoE ++) [90]. The same glucocorticoid dose was used in the first 5 days, but the rate of tapering thereafter differed between treatment groups. This has to be set against the advantages of accurate, timely diagnosis of GCA, in particular the potential cost savings of avoiding unnecessary treatment of patients without the disease. 2. In a multicentre RCT [52], one of the treatment arms received subcutaneous tocilizumab every 2 weeks rather than weekly; patients in this treatment arm also reached the primary endpoint, although it appeared to be less efficacious in relapsing patients. Introduction The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR-BHPR) guidelines for management of polymyalgia rheumatica (PMR) were published in 2010, aiming to provide guidance for diagnosis, management and disease monitoring. Tanaz A. Kermani – received consultancy fees from AbbVie in March 2018. Additional advantages of FDG-PET and CT therefore include potential value in the workup of alternative diagnoses such as malignancy and infection. Dario Camellino – received travel expenses, consultancy fees and speaker fees from AbbVie, Celgene, Janssen-Cilag, Eli Lilly, Mylan and Sanofi. Relapse is the recurrence of symptoms of PMR or onset of GCA, and not just unexplained raised ESR or CRP. 2006 May;67(5):240-3. doi: 10.12968/hmed.2006.67.5.21062. The effect of MTX has been investigated in three RCTs: a single-centre, 24-month, double-blinded RCT (n = 42) of patients with recent-onset GCA compared the addition of MTX 10 mg/week, vs placebo, to oral prednisone (initial prednisone dose of 60 mg/day) [98]. Muratore F, Kermani TA, Crowson CS et al. QoE: +++. Das CRP kann auch nur leicht erhöht sein; Manchmal normochrome normozytäre Anämie; Rheumafaktoren, ANA und andere Auto-AK sind negativ. BSR und/oder CRP meist erhöht. Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. First-line treatment options. Gonzalez-Gay MA, Garcia-Porrua C, Pineiro A et al. No recommendation can be made for the use of modified-release prednisone in the treatment of GCA. Hypertension and ischaemic heart disease were also identified as potential risk factors for cranial ischaemic complications in studies from Italy and Spain [33, 34]. Risk factors for aortic aneurysms: Inflammation of the aorta is associated with subsequent development of aortic dilatation or aneurysm [36], and those GCA patients with dilatation of the subclavian arteries were found to be more likely to have subsequent aortic aneurysm than those with GCA-related subclavian stenosis [37]. Visual loss or stroke may occur in GCA, attributed to vascular occlusion; most GCA-associated visual loss occurs prior to glucocorticoid treatment or shortly after treatment initiation, underlining the importance of immediate treatment if the disease is strongly suspected [5, 6]. 2020 Apr 24;4:21. doi: 10.1186/s41927-020-00121-y. The final versions were voted on by the working group and a consensus score generated for each statement, defined as the mean value of scores of all the individual working group members. Dasgupta B(1), Borg FA, Hassan N, Barraclough K, Bourke B, Fulcher J, Hollywood J, Hutchings A, Kyle V, Nott J, Power M, Samanta A; BSR and BHPR Standards, Guidelines and Audit Working Group. Comorbidities also should be taken into account, since the toxicity of glucocorticoid therapy increases with the dose [49]. Mackie SL, Hensor EM, Morgan AW, Pease CT. Hachulla E, Boivin V, Pasturel-Michon U et al. Statistical heterogeneity was assessed by considering the chi-squared test for significance at P < 0.1 and an I2 inconsistency statistic of >50% to indicate significant heterogeneity. Compared with biopsy, imaging tests such as ultrasound have the advantage of access to both superficial temporal arteries in their entirety. Consensus score: 9.47. Two members of each group independently performed screening, inclusion/exclusion of articles, data extraction and quality appraisal. More Primary Care research Into PMR. 1). An edited version of the BSR and BHPR guidelines for the management of polymyalgia rheumatica Bhaskar Dasgupta et al Rheumatology 2010 49(1):186-190 The diagnosis of PMR should start with the evaluation of core inclusion and exclusion criteria, followed by an assessment of the response to a standardized dose of steroid. Susan Mollan – advisory board member and received speaker fees from Roche/Chugai, representative of the Royal College of Ophthalmologists, co-author of the EULAR GCA guideline group and co-author of the European Headache Federation GCA guideline group. Vaidyanathan S, Chattopadhyay A, Mackie SL, Scarsbrook AF. Clin Med (Lond). We evaluated the quality of evidence using the approach set out by GRADE [20, 21] and implemented as follows: Risk of bias: Confidence in the estimate of the effect decreases if studies have major limitations that may bias their results. 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Consensus score: 9.61. This data extraction form included the following items: authorship and publication, design, main study population, primary study objective(s), links/overlap with other studies, study inclusion criteria, characteristics of participants, definition of intervention/exposure and control, definition of outcome, method of statistical analysis, length of follow-up, losses to follow-up, missing data, discrete/continuous data (counts, means, standard deviations etc. QoE: +. Using the evidence profiles, recommendations were proposed for each key question according to the GRADE methodology [24]: The GRADE system offers two grades of recommendations: ‘strong’ and ‘conditional’. The QoE was +; downgraded because of risk of bias, indirectness and imprecision [81]. Bhaskar Dasgupta – received consultancy fees for membership on clinical trials advisory boards and for developing trial protocols; speaker fees from Roche-Chugai, Sanofi, ERT, Bristol-Myers Squibb, GlaxoSmithKline and AbbVie and ultrasound workshop/GCA symposium grants to Southend University Hospital; honorary president of PMRGCAuk; television appearance on BBC2 health program ‘Trust me, I’m a doctor’, released February 2017. However, aortic imaging as a routine screening test for all GCA patients remains of uncertain cost-effectiveness and the optimal method and timing of imaging in this context is still unclear [44]. A preliminary list of PICO questions was identified by a face-to-face discussion at the first guideline development group meeting followed by an e-mail-based survey of the working group. By expert consensus where current evidence alone can not provide a definite.... 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