Predicting the risk of relapse in polymyalgia rheumatica: novel insights

ABSTRACT

Introduction

Polymyalgia rheumatica (PMR) is a common inflammatory disease found in people older than 50 years of Northern European descent. It is characterized by pain and stiffness in the shoulders, arms, hips, and neck. Relapses are common in patients with PMR.

Areas covered

This review describes when and how relapses occur in patients with PMR. Potential predisposing factors associated with relapses and management are also discussed. An extensive literature search on the PubMed database was conducted for publications on ‘polymyalgia rheumatica’ AND ‘relapses’ AND ‘risk factors’.

Expert opinion

Relapses are common in PMR being observed in approximately half of the patients. They often occur when the dose of prednisone is below 5–7.5 mg/day. The speed of glucocorticoid tapering is considered to be the main factor influencing the development of relapses in isolated PMRs. In addition, a genetic component may favor the presence of relapses in isolated PMRs. HLA-DRB1*0401 alleles were associated with an increased risk of relapse. An implication of the IL-6 promoter −174 G/C polymorphism and the GG241 ICAM-1 genotype  was also reported. With regard to serological biomarkers, elevated levels of angiopoietin-2 were associated with an unfavorable course of PMR. Methotrexate and anti-IL6 receptor antibody tocilizumab may be required in PMR patients with multiple relapses.

KEYWORDS:

• Polymyalgia rheumatica
• giant cell arteritis
• relapses
• glucocorticoids
• prednisone
• methotrexate
• anti-IL6-receptor tocilizumab

Declaration of interest

DP-P is supported by a research contract from the Carlos III Health Institute of Spain (Rio Hortega program, ref. CM20/00006) and has received grants/research supports from UCB Pharma, Roche, Sanofi, Pfizer, AbbVie and Lilly and the Spanish Foundation of Rheumatology (FER-GALAPAGOS program). SC has received grants/research support from Amgen, MSD and Pfizer, and has received consultation fees in the company sponsored speaker’s bureau from Amgen, Lilly, MSD, Novartis, Sanofi, Sobi, Stata and UCB. BA-M received grants/research supports from Kern Pharma, AbbVie, Pfizer, Celgene and GSK. RB received grants/research supports from Abbvie, MSD and Roche, and had consultation fees/participation in the company sponsored speaker´s bureau from Abbvie, Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma, and MSD. MAG-G has received grants/research supports from Abbvie, MSD. Janssen and Roche and had consultation fees/participation in the company sponsored speaker´s bureau from Abbvie, Pfizer, Roche, Sanofi, Lilly, Celgene, Sobi, Amgen and MSD. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers in this manuscript have no relevant financial or other relationships to disclose.

Article highlights

• Relapses are common in patients with isolated PMR.

• They generally occur when the dose of prednisone is less than 7.5 mg/day.

• Relapsing patients present characteristics of polymyalgia similar to those observed at the time of diagnosis of the disease.

• Relapses are generally associated with elevated ESR or CRP, but not in all cases.

• The rate of reduction in prednisone (speed of tapering) and a potential genetic component are associated with the risk of relapse in PMR.

• In general, improvement in relapses is achieved by increasing the dose of prednisone.

• Alternative therapies such as methotrexate or anti-interleukin (IL) −6 biologic therapy are used as glucocorticoid sparing agents in patients with relapsing PMR.

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Additional information

Funding

This work was partially supported by RETICS Programs, RD08/0075 (RIER), RD12/0009/0013 and RD16/0012 from ‘Instituto de Salud Carlos III’ (ISCIII) (Spain). However, this study did not receive any specific grant from funding agencies in the commercial or not-for-profit sectors.