Fast track clinics -the future of PMR care? Save

As the month dedicated to PMR draws to a close, we begin to look to the future, and what the ideal management of PMR looks like. 

Fast track clinics have revolutionised the management of giant cell arteritis (GCA), resulting in superior patient outcomes by facilitating early and accurate diagnosis and the instigation of appropriate and timely management. Until very recently, the importance of the management of PMR in specialist hands was underappreciated, and indeed without the presence of a concomitant GCA ,it was considered a relatively benign condition.

In most countries, PMR continues to be managed predominantly in primary care, with difficult or refractory cases subsequently being referred onto rheumatologists. Throughout the past month, many contributors have shown the importance of the specialists role, however the debate remains as to the stage of care at which a rheumatologist becomes involved. Waiting lists are long, and typically a patient is months into therapy prior to specialist review. 

There are a number of issues associated with this including:

1. PMR poses arguably one of the greatest diagnostic challenges in rheumatology. Absolutely, there are patients who present with the typical constellation of symptoms and signs, accompanied by raised acute phase reactants, and have a rapid and indeed sustained response to a typical low-moderate dose PMR steroid taper. But for a significant majority, this is not the case. The reasons for this are multiple, including an incorrect initial diagnosis with one of its many mimics in fact being the correct diagnosis, or indeed patients may have a concomitant GCA. Once steroid therapy has being commenced and maintained for a presumed diagnosis of PMR, it  muddies the water, and indeed heightens the diagnostic challenge and ability to accurately identify an alternative diagnosis. 
2. Once steroid therapy is commenced in primary care, it is seldom discontinued even in those with an inadequate response. The default is to increase the dose, and therefore by the time individuals are seen they often have a significant cumulative steroid burden, with many experiencing adverse effects, and in some cases, their original  symptomatology remains debilitating. This has an effect on mood and indeed quality of life. We are aware that the patients typically affected by PMR are those over 50, with the majority over 65. This potential unnecessary steroid burden in this vulnerable population can have disastrous consequences, and is frankly unacceptable in the year 2023. 
3. Serious mimics of PMR may be missed, most notably infection and malignancy. 
4. Other inflammatory rheumatic diseases, including alternative vasculitides (ANCA), inflammatory myopathies and indeed inflammatory arthritides such as late onset Rheumatoid arthritis can be missed. Once on steroid therapy, the assessment for these conditions can be a lot more difficult for a rheumatologist, not only clinically but also with laboratory and imaging methods. 
5. Non inflammatory conditions such as osteoarthritis are also mimics of PMR, and so if these conditions are mistaken for PMR, you confine an elderly, potentially vulnerable patient to a year of unnecessary high cumulative steroid burden. 
6. Patients not adequately assessed for a concomitant GCA may be massively undertreated with standard PMR steroid tapers, and suffer serious complications including vision loss, aneurysm formation and rupture.
7. Over the past decade advancements in imaging modalities have revealed PMR as a musculotendinous condition, and there are typical ultrasound (US) findings which have been incorporated into the 2012 EULAR/ACR classification criteria. Most rheumatology centres have expertise in musculoskeletal US, however, again once steroid therapy is commenced, the typical supporting US features melt away. 

A proposed fast track clinic model 

Over the past year we have implemented a fast track clinic for PMR at our institution in Dublin, Ireland to circumvent the above outlined issues in an attempt to optimise patient outcomes and indeed assess its feasibility as part of our general rheumatology service. Patients are referred predominantly from primary care, and we aim to see patients within a one to two week window. Referral criteria requires patients to have bilateral shoulder and/or pelvic girdle pain and stiffness, with elevated c-reactive protein and/or erythrocyte sedimentation rate. More recently, we have further defined the criteria to stipulate patients must not be on steroid therapy at the time of review.

At the initial clinic visit, each patient undergoes a thorough history and physical examination by a rheumatologist, where mimics are actively sought out, particularly infection, malignancy, symptoms or signs suggestive of an ANCA vasculitis or an inflammatory myopathy/ arthropathy. Concomitant GCA is also actively sought out in the history and clinical examination.

Following this, all patients undergo an ultrasound of both their shoulders at a minimum. This has proven extremely useful in identifying not only findings suggestive of PMR (such as bilateral subacromial subdeltoid bursitis), but also identifying mimics, such as severe osteoarthritis or a crystalline arthropathy. Where there is a suspicion of GCA, patients undergo US of their temporal and axillary arteries bilaterally. If needed based on clinical assessment, alternative imaging modalities are scheduled.

All patients undergo routine laboratory evaluation, in addition to assessment of thyroid function, anti-CCP antibodies, rheumatoid factor  and serum protein electrophoresis. Where there is suspicion of ANCA vasculitis or an inflammatory myopathy, relevant labs are also sent.  All patients get a vitamin D level checked, and a DEXA scan is booked for those with a final diagnosis of PMR. Baseline lipids and HbA1c are also checked, as is blood pressure.

Patients with a final diagnosis of PMR, are commenced on a typical starting dose of prednisolone of 15mg, and are co-prescribed vitamin D, in addition to a bisphosphonate. 

Our three key take home messages from running our fast track clinic are: 

• The patient should not be on steroid therapy at the time of review- ideally steroid naïve, but failing this they should be appropriately tapered off steroid.
• Actively seek alternative diagnoses keeping a broad differential including in particular infection, malignancy, ANCA vasculitis and inflammatory myopathies. 
• Actively screen for concomitant GCA both by clinical assessment, and where appropriate as a minimum US of temporal and axillary arteries.

The future….

Without a doubt, patient outcomes are far superior with the instigation of the fast track clinic as part of our service. Securing an accurate diagnosis from the start is crucial, and we have found that by appropriately managing patients from the beginning, their requirements for care, and demand on services, is in fact far less in the long term.

Over 40% of patients referred to our service, with a presumed diagnosis of PMR by their GP, actually had an alternative diagnosis. Among the alternative diagnoses we diagnosed patients with ANCA vasculitis, inflammatory myopathies, arthropathies and malignancies. Moreover, a concomitant GCA was diagnosed in approximately 5% of those initially referred in with a query over isolated PMR. The review by a specialist to make an initial accurate diagnosis off steroid therapy is paramount, and we feel should be part of routine care for those with presumed PMR.

Arguably, the percentage of patients seen who subsequently do not have PMR is quite high. Whilst certainly more stringent referral criteria needs to be defined, one may also consider that these are patients who would have been incorrectly managed with PMR steroid tapers in the community, resulting in potential increased morbidity, and at the more serious end of the spectrum, even mortality from a mismanagement of their true diagnosis. Arguably these patients will ultimately come to the attention of a rheumatologist, however, usually this will be months into their therapy when they now have significant morbidity, and potential complications from their initial missed diagnoses, ultimately leading to increased healthcare utilisation and expenditure.

Whilst rheumatologists are already stretched thin in terms of resources, I do not think this justifies reducing the significance of the appropriate care of one of our most common inflammatory conditions in those over the age of 50. Although for many years we undervalued its significance, prior precedence is not an excuse for future suboptimal care.