Predictors of relapse, early escalation and 1-Year use of glucocorticoids in new-onset polymyalgia rheumatica: A prospective cohort study

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OBJECTIVE: A sub-population of patients with polymyalgia rheumatica (PMR) require early glucocorticoid (GC) escalation to achieve remission or have a relapsing disease course. This study aimed to investigate predictors of early GC escalation, risk of relapse, and treatment after year 1 with GCs. METHODS: Clinical and biochemical parameters from a prospective cohort of newly diagnosed patients with PMR were analysed. Diagnosis was confirmed after 1 year of follow-up. Outcomes were need for GC escalation to achieve remission between week 2 and week 4, relapse between week 10- and 1-year, and ongoing prednisolone treatment at 1-year follow-up. Prediction models with cut-off estimation were generated using ROC-curves. RESULTS: Sixty patients with a confirmed PMR diagnosis after 1-year of follow-up were included. CRP showed the most consistent predictive signal across all outcomes. CRP cut-off values for early prednisolone escalation were 41.5mg/L at baseline and 22.5mg/L at week 1 with sensitivities/specificities of 78%/73% and 88%/94%, respectively. CRP cut-off levels for predicting relapse were 49.5mg/L at baseline and 7.5mg/L at week 1 with sensitivities/specificities of 65%/86% and 100%/68%, respectively. Ongoing prednisolone treatment at 1-year demonstrated similar results as relapse. Refractory disease within 4 weeks significantly increased the risk of future relapse (OR: 3.7, 95%CI (1.01-10.58)), and ongoing prednisolone treatment at 1-year follow-up (OR: 4.84, 95%CI (1.51-15.5)) CONCLUSION: Monitoring of treatment response within the first one week after diagnosis may help identify patients requiring early glucocorticoid escalation and those at risk of a more severe disease trajectory and may be part of individualized management of PMR.

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