Toby Helliwell

Is cancer associated with polymyalgia rheumatica? A cohort study in the General Practice Research Database

Objective To investigate the incidence of new cancer diagnoses in a community sample of patients with polymyalgia rheumatica (PMR). Methods All incident cases of PMR in the UK General Practice Research Database (GPRD) (1987–99), without pre-existing cancer or vascular disease and treated with corticosteroids (n=2877) were matched with up to five age, sex and GP practice patients without PMR (n=9942). Participants were followed up until first cancer diagnosis, death, transfer out of the database or end of available records. Results The mean age of the sample was 71.6 years (SD 9.0), 73% were female. Median follow-up time was 7.8 years (IQR 3.4, 12.3). 667 (23.2%) people with a PMR diagnosis developed cancer compared with 1938 (19.5%) of those without PMR. There was an interaction between PMR status and time. In the first 6 months after diagnosis, those with a PMR diagnosis were significantly more likely to receive a cancer diagnosis (adjusted HR (95% CI): 1.69 (1.18 to 2.42)). The number of events was small, but occurrences of prostate, blood, lymph nodes, female reproductive and nervous system cancers may be more common in those with PMR in the first 6 months after PMR diagnosis. Conclusions An increase in the rate of cancer diagnoses was noted in the first 6 months of observation, but we were unable to determine whether the cancer incidence in PMR was different from controls, beyond this time point. Clinicians should ensure they fully exclude cancer as a cause of PMR-like symptoms and monitor patients for possible malignancies.

Risk of vascular events in patients with polymyalgia rheumatica

Background: Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events. Methods: We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica. Results: A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis. Interpretation: Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.

Development of a Provisional Core Domain Set for Polymyalgia Rheumatica: Report from the OMERACT 12 Polymyalgia Rheumatica Working Group

Objective. The Outcome Measures in Rheumatology (OMERACT) polymyalgia rheumatica (PMR) working group aims to develop a core set of outcome measures to be used in clinical trials for PMR. Previous reports from OMERACT 11 included a qualitative study of the patient experience and a preliminary literature review. Methods. A 3-round Delphi survey of clinicians and patients with PMR was undertaken to identify a candidate core domain set for PMR research. Additionally, a literature review of outcome measures and their respective measurement instruments was undertaken. Meetings of patient research partners and clinicians were convened to review face validity of the provisional core domain set, which was subsequently presented and discussed at the OMERACT 12 congress. Results. Of the 60 clinicians taking part in round 1, 55 took part in round 2 and 51 in round 3. Of the 55 patients who took part in round 1, 46 and 35 took part in subsequent rounds. In total, 91% of participants in round 3 deemed the resulting draft core domain set reasonable. The literature review identified 28 studies for full review. Measurement instruments for each proposed domain were identified. Clinicians are highly aware of glucocorticoid-related adverse effects, but there is relatively little evidence about their true prevalence and severity, especially in PMR. Conclusion. A provisional core domain set, presented for clinical trials in PMR, comprises acute phase markers, physical function, death, glucocorticoid-related adverse events, and development of giant cell arteritis. Measurement instruments are suggested that may cover each domain, but these require formal validation for clinical trials in PMR.

Polymyalgia rheumatica: diagnosis, prescribing, and monitoring in general practice

Background Polymyalgia rheumatica (PMR) is a common rheumatological disorder of older patients. The majority of UK patients are diagnosed and managed exclusively in general practice. In primary care, it has been shown that there is wide variation in practice, and established diagnostic criteria are infrequently used. Aim This study aims to investigate the diagnostic processes, management, and monitoring of patients with PMR in UK primary care. Design and setting This is a retrospective cohort study set in primary care. Method Data were extracted from two interlinked primary care databases from north Staffordshire. Patients with PMR were identified using Read Codes and the relevant investigation, prescription, and consultation data were extracted and reviewed. Results Three hundred and four patients’ records were analysed. Documentation of symptoms leading to a diagnosis of PMR was found in 248 records (81.6%). A documented process of exclusion of relevant differential diagnoses was demonstrated in 68 (22.4%) patients. The mean initial dose of prednisolone was 21.5 mg. Referral to specialist care was made for 135 (44.4%) patients. Gastric prophylaxis was prescribed in 85 (28.0%) cases. Osteoporosis prophylaxis was prescribed to 183 patients (60.2%); 12 patients (3.9%) developed osteoporosis and 56 (18.4%) developed gastric symptoms that led to GP consultation. Conclusion The management of PMR in general practice could be optimised. Identified areas for improvement include clear documentation of a process of exclusion of other diagnoses, and prophylaxis for potential treatment complications, including osteoporosis and gastric symptoms.

Diagnosis and management of giant cell arteritis

Giant cell arteritis (GCA) is the commonest form of large-vessel vasculitis and affects branches of the external carotid artery but also the ciliary and retinal arteries. The symptoms are caused by local ischaemia due to endovascular damage and cytokine-mediated systemic illness. There is considerable overlap with polymyalgia rheumatica (PMR): 16–21% of patients with PMR have GCA on temporal artery biopsy, and symptoms of PMR are present in 40–60% of patients with GCA.1 GCA occurs in 2.2 per 10 000 patient-years in the UK.2 A full-time GP may expect to see one new case every 1–2 years. It is virtually unknown in people aged under 50 years. Early recognition is critical to prevent visual loss, that otherwise occurs in up to 20% of cases.3 Once high-dose corticosteroids are started, visual loss is extremely rare. Guidelines for the diagnosis and management of GCA, have recently been published by the British Society of Rheumatologists and British Health Professionals in Rheumatology.4 A 2002 systematic review analysed the presenting clinical features in a mixture of studies, with a total of 1435 cases of giant cell arteritis.5 The mean duration of symptoms at diagnosis was 3.5 months.5 The …

Diagnosis and management of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disorder affecting older people.1 Patients typically present with bilateral shoulder pain, morning stiffness, raised inflammatory markers, and have a rapid response to low-dose corticosteroids. There is no gold standard diagnostic test and despite being first described in 1888, controversies still exist as to its defining characteristics. PMR carries a lifetime risk of 2.4% for females and 1.7% for males.2 The incidence in the UK has been shown to be 8.42 per 10 000 person years.3 In the UK, the majority of patients are managed exclusively in primary care4 with an average full-time GP seeing five new cases of PMR per year.5 Accurate diagnosis can be challenging even for specialists, but is essential as many serious illnesses can mimic PMR. Guidelines for the diagnosis and management of PMR have recently been published by the British Society of Rheumatologists (BSR) and British Health Professionals in Rheumatology (BHPR).6 Consider PMR in patients over the age of 50 years with: Subsequent clinical assessment and investigations should …

The epidemiology of polymyalgia rheumatica in primary care: a research protocol

BackgroundPolymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition.MethodsPatients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers.DiscussionThis will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

What is the impact of giant cell arteritis on patients' lives? A UK qualitative study

Objectives Clinical management of giant cell arteritis (GCA) involves balancing the risks and burdens arising from the disease with those arising from treatment, but there is little research on the nature of those burdens. We aimed to explore the impact of giant cell arteritis (GCA) and its treatment on patients’ lives. Methods UK patients with GCA participated in semi-structured telephone interviews. Inductive thematic analysis was employed. Results 24 participants were recruited (age: 65–92 years, time since diagnosis: 2 months to >6 years). The overarching themes from analysis were: ongoing symptoms of the disease and its treatment; and ‘life-changing’ impacts. The overall impact of GCA on patients’ lives arose from a changing combination of symptoms, side effects, adaptations to everyday life and impacts on sense of normality. Important factors contributing to loss of normality were glucocorticoid-related treatment burdens and fear about possible future loss of vision. Conclusions The impact of GCA in patients’ everyday lives can be substantial, multifaceted and ongoing despite apparent control of disease activity. The findings of this study will help doctors better understand patient priorities, legitimise patients’ experiences of GCA and work with patients to set realistic treatment goals and plan adaptations to their everyday lives.

Research into practice: improving musculoskeletal care in general practice

Musculoskeletal disorders such as back pain, neck pain, osteoarthritis, and rarer conditions like gout and inflammatory arthritis are the most common limiting long-term conditions in the UK.1 They represent a huge and growing burden on population health, accounting for 30% of all years lived with disability, and 7.5 million days lost from work each year. The challenge was recognised by the Chief Medical Officer and confirmed in the recent Global Burden of Disease report: ‘Although health-care cost and activity data confirm that these conditions consume massive UK health system resources, concerted public health and high-quality integrated medical care strategies are not implemented systematically. Interventions are available for musculoskeletal disorders, but to what extent the health system is delivering is unclear. Musculoskeletal disorders will only increase in importance in view of present trends and require more urgent policy attention.’ 1 General practice and primary care more generally have a critical role in meeting these challenges. Of the 300 million general practice consultations that occur in England every year, approximately one in six are for arthritis and musculoskeletal problems. An important feature of primary care is its capacity to address the needs of patients with long-term conditions such as musculoskeletal complaints; this includes responsibility for anticipatory and preventive care across the life-course, supporting patients to self-manage their condition, and delivery of evidence-based clinical treatment. Effective primary health care can improve the health and wellbeing of individual patients and their families, and reduce the health and economic impact of musculoskeletal disorders on the population as a whole. The Research Institute for Primary Care and Health Sciences at Keele University is a multidisciplinary collaboration between academics from general practice, clinical rheumatology, epidemiology, physiotherapy, psychology, and health services research, and clinical partners across the West Midlands and Cheshire. …

ESR can be normal in giant cell arteritis and polymyalgia rheumatica

It is potentially dangerous to suggest that normal inflammatory markers can be used to rule out illnesses such as giant cell arteritis and polymyalgia rheumatica.1 Although patients with polymyalgia rheumatica will …