Best of 2023: PMR: glad or bad tidings?

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Please don’t tell your patient that PMR “typically” lasts two years. According to real-world data from the UK, one in four patients with PMR is prescribed steroids by their primary care physician for over four years. But nobody tells them this at the start, and that causes big problems later on.

Advancing PMR

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Even though polymyalgia rheumatica is not perceived by many physicians as a severe diagnosis, its diagnosis and management actually propose significant challenges. I'd like to talk about those challenges, and what directions our path forward can include to advance our understanding and improve the treatment of patients who have PMR.

JAKi for PMR: Safe, or a Concern for Older Adults?

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JAK inhibitors obviously have dominated a lot of the discussion in our therapeutic landscape over the last couple of years. What about their use in polymyalgia rheumatica? Let's consider.

When PMR Strikes Young, It Hits Hard

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Narratives around polymyalgia rheumatica (PMR) often centre around “older people” or even “elderly”. And, indeed, the peak of the age distribution is in the mid-70s – not that everyone that age considers themselves old. Treating “young PMR” can be a very different proposition to treating someone in their seventies or eighties. It’s worth taking time to think this through.

Impact of glucocorticoids: more than just toxicity

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As the sole effective treatment for polymyalgia rheumatica since their development in the 1950’s until recently, the impact of glucocorticoids and PMR outcomes are undeniably intertwined. So much so that when the OMERACT PMR working group first set out to develop a PMR core outcome set, they quickly realised that many of the outcomes important to patients were related to their glucocorticoid use.

Universal Imaging for GCA in PMR? Not So Fast

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For decades we've been screening GCA with a patient history and exam. Doing so with imaging would be a sharp departure from the current standard of care. And you may be asking yourself, well, yeah, but what could it hurt? Don't you want to catch GCA early?  Let me tell you the problems with this. 

What Causes PMR?

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What causes polymyalgia rheumatica? It could be said that PMR occurs when trajectories of aging take a wrong turn, but it’s still not clear exactly what it is that causes this to happen. The ideas that follow will doubtless seem, to immunologists, vague and oversimplified; but even a partial picture might still offer a possible framework for clinicians and patients for thinking about treatment and care.

What Goes Wrong with the Immune System in PMR?

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Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disease. The exact trigger for PMR onset remains unknown. However, immunology studies and clinical trials with biological DMARDs now shed light on the immune pathways involved in PMR.

Using Methotrexate in PMR

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Treatment of PMR is still largely based on glucocorticoids. Where in other inflammatory rheumatic disorders, such as RA and PsA, early initiation of methotrexate is common practice, this is not the case in PMR. 

Frailty in PMR: Why do I need to care?

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It is important to clarify that frailty is not a synonym of age (chronological age). Although there are only a few studies studying the impact of frailty in PMR, frailty is a relevant issue due to several important factors.

IL-6 Inhibitors in PMR: Give early or late?

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It's exciting to be able to have this conversation because it's only in the past year that we have an approved non-corticosteroid therapy for PMR that's been shown to be effective in a well done clinical trial.

PMR: glad or bad tidings?

Save

Please don’t tell your patient that PMR “typically” lasts two years. According to real-world data from the UK, one in four patients with PMR is prescribed steroids by their primary care physician for over four years. But nobody tells them this at the start, and that causes big problems later on.