• ACPA - Anti-Citrullinated Peptide Antibodies
  • US - Ultrasound
  • Reference: ACR 2012 Proposed PR Criteria
ACR 2012 PR Diagnostic Criteria
PR diagnosis - ALL patients MUST have the following:
  • Age ≥ 50 years
  • Bilateral shoulder aching
  • Elevated ESR or C-reactive protein
If the above criteria are met, then the diagnosis is based on a scoring system with the criteria below. The score required for diagnosis differs on whether ultrasound (US) results are available.
  • Criteria without US - score of ≥ 4 establishes PR diagnosis
  • Criteria with US - score of ≥ 5 establishes PR diagnosis
Criteria
Score
Morning stiffness for > 45 minutes
2
Hip pain or limited range of motion
1
Negative Rheumatoid factor or ACPA
2
Absence of other joint pain
1
When US results are available
At least 1 shoulder with subdeltoid bursitis and/or biceps tenosynovitis and/or glenohumeral synovitis (either posterior or axillary) and at least 1 hip with synovitis and/or trochanteric bursitis 1
Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis 1




Polymyalgia rheumatica treatment
Medications
  • Corticosteroids are the standard treatment for PR
  • Other therapies - methotrexate, azathioprine, tumor necrosis factor inhibitors - have been studied in small trials, but no conclusive benefit has been found [1]
    • The British Society of Rheumatology published the following recommendations in 2010:
      • Prednisolone or prednisone 15 mg a day for 3 weeks
      • Then 12.5 mg for 3 weeks
      • Then 10 mg for 4 - 6 weeks
      • Then reduction by 1 mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5 mg alternate days, etc.)
      • Typically, 1-2 years of treatment are needed
      • An alternative regimen with IM methylprednisolone is given as: 120 mg IM every 3-4 weeks, reducing by 20 mg every 2-3 months [7]
Relapse
  • Relapse is common - up to 50% of patients [1]
Complications
  • Side effects of chronic steroid use - see corticosteroids
  • Increased risk of peripheral artery disease
  • Development of GCA [1]

Giant cell arteritis treatment
Medications
  • Corticosteroids are the standard treatment for GCA
  • In 2017, the FDA approved tocilizumab, an IL-6 receptor inhibitor, for the treatment of GCA. Approval was based on results from the tocilizumab vs placebo study detailed below.
  • Low-dose aspirin may lower the risk of stroke and vision loss, although the evidence is not conclusive
  • Methotrexate has had mixed results in trials. Tumor necrosis factor inhibitors have not been found to be beneficial. Other disease-modifying drugs (e.g. azathioprine) have shown no conclusive benefit. [5,8]

  • The British Society of Rheumatology published the following recommendations in 2010:
    • GCA without jaw or tongue claudication or visual symptoms:
      • Prednisolone or prednisone 40 - 60 mg (not < 0.75 mg/kg) daily for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 - 4 weeks to 10 mg
      • Then by 1 mg every 1 - 2 months provided there is no relapse
    • GCA with visual symptoms:
      • Evolving visual loss or history of amaurosis fugax: IV methylprednisolone 500 mg to 1 gram daily for 3 days
      • Established vision loss: at least 60 mg prednisolone or prednisone daily
      • Continue for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 - 4 weeks to 10 mg
      • Then by 1 mg every 1 - 2 months provided there is no relapse [8]
Relapse
  • Relapse is common - up to 77% of patients who discontinue corticosteroids [5]
Complications
  • Side effects of chronic steroid use - see corticosteroids
  • Vision loss from narrowing or occlusion of the posterior ciliary arteries or retinal artery occlusion
  • Thoracic aortic aneurysms
  • Aortic dissections
  • Neuropathies [1,8]