Australian rheumatologists significantly vary in how they diagnose and manage polymyalgia rheumatica, with notable gaps in recognising atypical features, accessing imaging, and addressing physical therapy, a survey suggests.
Researchers say their findings published in the Internal Medicine Journal [link here] have shone a spotlight on the “overall inadequacy of current management strategies” across Australian practice and the need for standardised, evidence-based clinical care guidelines.
Dr Jessica Leung.
Led by Austin Health’s Dr Jessica Leung and Professor Claire Owen, the team surveyed 79 rheumatologists and trainees managing polymyalgia rheumatica (PMR), with the vast majority of respondents seeing a patient with PMR at least fortnightly.
Most surveyed rheumatologists relied on reported symptoms and markers of inflammation to make a PMR diagnosis, however, concerningly, there was disagreement on how the inflammatory condition might present in patients.
While most (80%) respondents recognised peripheral joint involvement as a possible feature of PMR, 13% did not and 7% were unsure. Those who believed the presence of hand and/or wrist symptoms precluded a PMR diagnosis instead indicated that they would classify the patient as PMR-onset seronegative RA.
Another contentious topic was inflammatory markers in PMR, with as many as a third of clinicians indicating that every patient exhibited elevated markers like ESR and CRP at diagnosis, despite the literature stating this wasn’t always the case.
“While this group does not represent the majority, it is crucial for clinicians to remain open to the possibility of a PMR diagnosis and not automatically disregard it based on this assumption,” said the researchers, who included past ARA president Professor Catherine Hill and current president Dr Helen Keen.
The majority (79%) of clinicians reported not routinely arranging imaging such as F-fluorodeoxyglucose (F-FDG) PET/CT when making a diagnosis, but despite the limited use, 72% agreed imaging was useful in cases of diagnostic uncertainty.
The most commonly used imaging modalities were ultrasound (52%), F-FDG PET/CT (39%), X-ray (34%) and MRI (24%), with several respondents expressing frustration around their lack of access to F-FDG PET/CT in the free-text responses.
PMR management mainly involved glucocorticoid monotherapy; however, almost every clinician (98%) reported having prescribed a conventional synthetic DMARD for its steroid-sparing effects, with half noting this was required in at least one quarter of patients. Methotrexate and leflunomide were the most frequently used csDMARDs, with clinicians acknowledging the lack of evidence on efficacy.
Other areas of significant heterogeneity included the use of guideline-recommended adjunctive physical therapy. While one in four clinicians addressed exercise for most of their patients, one in four reported they had never provided advice around exercise or referred their patients to an allied health practitioner.
Many responses also opposed established perceptions of PMR as a benign and self-limiting condition, as well as expressed differing views on the required duration of glucocorticoid therapy, which were both topics that were “being increasingly challenged” by the recent literature, the researchers noted.
“It accordingly seems unsurprising that survey respondents’ perceptions regarding long-term outcomes for PMR were so varied given the apparent disconnect that exists between conventional teaching and modern clinical experience,” they said.
“It is hoped that these insights will provide a starting point for future improvements in the standard of care available to patients living with PMR in Australia,” they concluded.