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Unpopular opinion: spinach can be bad for you

The title might have misled you; I am absolutely not addressing the health benefits or lack thereof of daily consumption of spinach. Simply, Dr Stephen Paget’s analogy comparing the drastic response to steroids in PMR to Popeye’s spinach stuck with me! 

During this month’s “Make Rheum for PMR” campaign, you are listening to experts from around the world discuss all the important aspects of diagnosing and treating PMR. 

As many rheumatologists stated, PMR might be one of the most rewarding diagnoses to make in real practice: the patient comes to you in severe debilitating pain, and you prescribe steroids, giving them their lives back! As much as this impressive response makes your intervention appear almost magical, there is the often-forgotten story about the implications of such a diagnosis and treatment on patients' daily lives. 

So let me get your opinion on some issues that come up in my daily practice.

1-Should we tell the patients newly diagnosed with PMR that they might be considered immunosuppressed because of prolonged steroid exposure? 

In fact, the Centers for Disease Control and Prevention (CDC) ‘immunosuppressive therapy’ guidelines, states that glucocorticoid (GC) usage for ≥2 weeks in dosages equivalent to prednisone of 20 mg/d or 2 mg/kg body weight are considered immunosuppressive. The level of immunosuppression in the case of a long-term treatment with low dose GC remains less clear. 

This obviously has implications on how you counsel the patient regarding high-risk exposures, what to do and what to expect if they have a fever or cold symptoms, if an elective surgery is planned.... 

Leading me to the following question.

2-How often do we counsel patients with newly diagnosed PMR about vaccinations?

And should this be addressed early-on rather than when they are already on steroids for a few months? For some of the patients, the indications are more streamlined if they are 65 years of age and older. 

It gets trickier for those who are less than 65 years of age: should they get the regular or high dose flu vaccine, should they be offered the pneumonia vaccine and shingles?

3- Should we be obtaining a screening hepatitis profile and QuantiFERON TB at baseline?

You might ask why? I can think of two reasons: 

-Our patient will be on a prolonged course of steroids, with the possibility of introducing a steroid sparing agent if needed/in certain scenarios down the line. The limitation of sending a QTB after prolonged steroid use is the risk of getting back an indeterminate result that might lead to additional testing. Or you might prefer a ‘deal with it when it happens’ approach?

-Rule out chronic/occult infection as a mimicker? I quote a dear colleague: “It could be ageist assumptions that older people don’t have interesting lifestyles” 

4-The dreaded mimicker: Are we asking the patients if they are up to date with age-appropriate screening? If they are not, should we be more proactive and maybe work with their primary care physician to ensure they are?

You can imagine how the new onset of constitutional symptoms in the setting of anemia and elevated inflammatory markers in an older patient would raise a red flag. Some of my colleagues routinely send serum/urine immunoelectrophoresis as part of their initial work up. I personally send an additional work up such as serum and urine protein electrophoresis and in some cases pursue imaging, in certain scenarios: when the inflammatory markers remain elevated out of proportion assuming that temporal arteritis +/- large vessel vasculitis have been ruled out, when constitutional symptoms persist mainly excessive fatigue and weight loss...

5-Finally, a “not my forte” area: Are we getting a baseline DEXA scan to screen for osteoporosis and/or addressing the need for preventative therapy against glucocorticoid induced osteoporosis? 

The American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis (PMID: 28585373) recommend obtaining a DEXA scan within the first 6 months of starting therapy and to risk stratify the patients to determine their need for preventive measures. This is particularly relevant in patients with PMR as they are already at higher risk of fractures and falls given age and comorbid conditions. 

As I stated at the beginning of this blog, our expert colleagues are weighing in on several important aspects regarding diagnostic and treatment challenges of PMR. I wanted to highlight here some of the questions that come up in real life practice when thinking about the patient as a whole. A reminder about the impact of giving a diagnosis that requires prolonged exposure to steroids. As a rheumatologist, we constantly strive to provide excellent, evidence-based care for our patients but ultimately struggle with the time restrictions imposed on us and the complexity of the patients. How much can you address in a 15- or 20-min visit? Some providers might opt to defer the “health care maintenance” aspect to the primary care physicians. This also has its own limitations as the general practitioner might not have the adequate resources to tackle all of these issues.

I look forward to seeing your answers and thoughts in the comment section below. 


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Lara El Khoury, MD, is Assistant Professor of Medicine in the division of Rheumatology and Associate Program Director of the Rheumatology Fellowship Program at Zucker School of Medicine Hofstra/Northwell in New York. I am passionate about medical education. My clinical and research interests are centered around vasculitis, mainly giant cell arteritis. I codirect the vasculitis center and I am in charge of the giant cell arteritis multidisciplinary pathway in our division.