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“Although the international recommendations and the wide consensus that glucocorticoids should be used as shorter as possible (ideally by 1–2 years), a high rate of prolonged steroid treatment is still recorded in the management of PMR,” investigators stated.
A high rate of long-term glucocorticoid (GC) treatment was reported in patients with polymyalgia rheumatica (PMR), according to a study published in Springer.1 This led investigators to hypothesize that other unidentified factors may be involved, and further research is necessary to identify patients with higher risk of relapse and utilize steroid-sparing strategies.
“There is a widely held perception that a significant gap exists between theory and daily clinical practice, where a large proportion of patients experiences relapses and prolonged treatment with steroids, resulting in increased exposure to the risk of GC-related adverse effects,” investigators explained. “Thus, accurate and reliable data on these potential critical issues in PMR management are needed to set the research agenda and possibly update the current recommendations.”
Investigators searched for studies across a variety of platforms, including PubMed, Scopus, and Cochrane Library, and performed a systemic review, according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols, to determine the prevalence and predictors of long-term GC treatment and any association of disease relapse. Patients with PMR treated with GCs were analyzed using the search terms “polymyalgia rheumatica,” “polymyalg,” and “rheumatic polymyalg.” The proportion of patients being treated with GCs at 1, 2, 3, 4, and 5 years were assessed.
Of the 5442 studies, 21 met meta-analysis criteria and 24 were used in the qualitative analysis. Patients still treated with GCs at 1 (77%), 2 (51%), and 5 (25%) years were accounted for. A subgroup analysis showed retention rates at 75% vs 78% at the 1-year mark, and 49% vs 55% at 2 years. Seven studies showed that 43% of patients experienced 1 or more relapses after the first year of GC initiation, with factors such as female gender, starting GC dosage, tapering regimen, and acute-phase reactants levels cited as some of the more frequent predictors. Nonetheless, these were met with inconsistent results.
There was no link between methotrexate (10 mg weekly) and a shorter GC treatment duration in a 5-year extension study. However, there was a significant association between being treated with the drug at baseline and long-term GC treatment in 1 observational study.
Peripheral arthritis did not predict relapse in 4 of the studies analyzed.
Age did not impact treatment duration, as only 1 of the studies reported an association between older age and longer exposure. Additionally, it was not associated with any of the studies in which relapse risk was analyzed. While 1 study linked female patients and relapse, it was the only study to identify female gender as a predictor of long-term GC usage.
Strengths of the study include an applied search strategy, which involved higher comprehensiveness in the search results, thus preventing missing eligible studies. It was also a reliable representation of clinical practice based on the selection of observational studies that analyzed scheduled treatment tapering timelines. However, the heterogeneity of the studies could be viewed as detrimental. Despite this, investigators believe the clinical significance and validity of the cases remain intact.
“Although the international recommendations and the wide consensus that GCs should be used as shorter as possible (ideally by 1–2 years), a high rate of prolonged steroid treatment is still recorded in the management of PMR,” investigators concluded. “The results of this study suggest that additional research is needed to understand the reasons for prolonged treatment, especially in patients who have not relapsed, enhance the adherence to the recommendations, develop evidence-based strategies for GCs tapering, clarify the role of MTX and other potential steroid-sparing agents, and identify biomarkers for an individualized disease management.”
Floris A, Piga M, Chessa E, et al. Long-term glucocorticoid treatment and high relapse rate remain unresolved issues in the real-life management of polymyalgia rheumatica: a systematic literature review and meta-analysis [published online ahead of print, 2021 Aug 20]. Clin Rheumatol. 2021;10.1007/s10067-021-05819-z. doi:10.1007/s10067-021-05819-z