ABS1037 RE-REFERRAL AND SECOND OPINION IN POLYMYALGIA RHEUMATICA: AN ASSESSMENT OF FREQUENCIES, REASONS, AND CLINICAL OUTCOMES

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Background: Approximately one-fourth of patients with established polymyalgia rheumatica (PMR) managed in primary care are referred for second opinion by a rheumatologist in secondary care [1]. Similarly, patients initially diagnosed with PMR in secondary care are recommended for re-referral if giant cell arteritis (GCA) is suspected or glucocorticoid (GC) tapering proves challenging [2]. However, the frequencies, reasons, and clinical outcomes of these referrals remain poorly understood. Objectives: To investigate the frequencies, reasons, and clinical outcomes of second opinion and re-referral of patients with PMR. Methods: This retrospective, single center, cohort study investigated referrals to the department of rheumatology at a university hospital with the ICD-10 code DM353 for PMR from 2018 to 2024. Inclusion criteria were an established PMR diagnosis and patients were categorized into two groups: 1) Patients initially diagnosed with PMR in primary care, referred for second opinion, and 2) Patients initially diagnosed with PMR at the department of rheumatology, who were discharged, and later re-referred. Individuals who did not receive a PMR diagnosis or with known concurrent GCA were excluded. Data were obtained from electronic patient records and included medical history, PMR-associated symptoms and signs, and laboratory and imaging results. Second opinion evaluation was defined as evaluation at the department of rheumatology following initial diagnosis in primary care. Relapse was defined as PMR disease activity occurring during GC treatment. Recurrence was defined as PMR disease activity emerging after GC discontinuation. Results: In group 1, 52 patients (26% of the 201 patients discharged after an initial diagnosis of PMR at the department of rheumatology) were re-referred and included in the final analysis. In group 2, 158 patients, initially diagnosed with PMR in primary care, were referred for second opinion, 110 by general practitioners and 48 by rheumatologists (hospital-based or in private practice). The 52 re-referrals were primarily due to relapses (46%) and recurrences (31%). Seventy-nine percent maintained their PMR diagnosis following re-evaluation (Table 1). The re-referred patients were discharged significantly earlier than those not re-referred (41 days [IQR: 0–142] vs . 241 days [IQR: 21–481], p<0.01) and were more often female (65% [95 CI: 53–76] vs . 54% [95 CI: 46–62], p<0.05). Figure 1 shows the timing of discharge. The main reasons for the 110 second opinion referrals from general practitioners were diagnostic uncertainty (56%) and relapses (24%) (Table 1). These patients were divided into the 55 with the shortest intervals between diagnosis and referral, and the 55 with the longest. Patients with the shortest intervals were younger (mean ± SD: 68.2 ± 9.4 years vs . 72.3 ± 9.0 years, p<0.05), less frequently female (44% [95 CI: 31–57] vs . 65% [95 CI: 52–79], p<0.05), and had higher C-reactive protein levels at evaluation (23.4 mg/L [IQR: 10–42] vs . 10.2 mg/L [IQR: 4–24], p<0.01) compared to those with the longest intervals. Sixty-three percent maintained PMR diagnosis (Table 1). There were no differences in the proportion of patients examined for and diagnosed with concurrent GCA, but PMR patients initially diagnosed in primary care were more likely to undergo diagnostic tapering of prednisolone, compared to those with an initial hospital diagnosis (Table 1). Conclusion: Despite an initial specialist diagnosis, the re-referral rate for PMR patients was high, particularly among those discharged early, suggesting that initiating GC tapering in a hospital setting may reduce re-referrals. The high uncertainty among general practitioners regarding the PMR diagnosis was justified, as one-third of the patients received alternative diagnoses after second opinion. In contrast, patients with initial hospital diagnoses were less likely to be re-referred due to diagnostic uncertainty, suggesting that hospital-based diagnoses reduce diagnostic ambiguity. No cases of late-onset concurrent PMR were observed amongst patients initially diagnosed by a rheumatologist, likely due to identification of prevalent cases during the initial rheumatological evaluation. REFERENCES: [1] Donskov, A.O., et al., An international survey of current management practices for polymyalgia rheumatica by general practitioners and rheumatologists. Rheumatology (Oxford), 2023. 62 (8): p. 2797-2805. [2] Keller, K.K., et al., Recommendations for early referral of individuals with suspected polymyalgia rheumatica: an initiative from the international giant cell arteritis and polymyalgia rheumatica study group. Annals of the Rheumatic Diseases, 2024. 83 (11): p. 1436-1442. Figure 1Time from Diagnosis to Discharge. Density plot showing the distribution of discharge timing ofPMR patients diagnosed at the department of rheumatology. The x-axis represents days from diagnosis to discharge, and the y-axis shows probability density, with the area under each curve summing to 1. Acknowledgements: NIL . Disclosure of Interests: Elisabeth Lindrup Nielsen: None declared, Agnete Overgaard Donskov: None declared, Andreas Wiggers Nielsen: None declared, Christoffer Våben: None declared, Line Lier Frølund: None declared, Ib Hansen: None declared, Line Thorndal Moll LTM has received speaking fees unrelated to this manuscript from Lilly, Berit Dalsgaard Nielsen BDN has received speaking fees unrelated to this manuscript from Novartis and AbbVie, Christoffer Mork: None declared, Ellen-Margrethe Hauge EMH has received grants unrelated to this manuscript from Novo Nordic Foundation, Roche, Novartis and personal fees from AbbVie, Sanofi, SOBI, Merck Sharp & Dohme and Union Chimique Belge. The remaining authors have declared no conflicts of interest, Kresten Keller: None declared. © The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 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