Polymyalgia rheumatica mit und ohne Großgefäßvaskulitis

Abstract

Polymyalgia rheumatica (PMR) is characterized by rapidly evolving shoulder and pelvic girdle pain with fatigue, weight loss, night sweats and elevated CRP and ESR. Giant cell arteritis (GCA) can occur in PMR and vice versa. Headache and scalp tenderness are typical for GCA. GCA may be complicated by visual loss or by strokes.

Imaging, particularly ultrasound, is helpful for distinguishing PMR from similar conditions such as shoulder osteoarthritis, rheumatoid arthritis and chondrocalcinosis. Subdeltoid bursitis, biceps tenosynovitis and hip joint effusions are common in PMR. The diagnosis of GCA needs to be either confirmed by imaging or by histology. Ultrasound is the imaging method of choice provided that expertise and adequate equipment are available. Inflamed arteries exhibit a concentric wall thickening. Patients with extracranial GCA are younger, more often female. Vasculitis commonly involves the aorta, subclavian arteries, axillary arteries and other arteries. The diagnosis of extracranial GCA may be confirmed by ultrasound, CT, MRI or PET.

Prednisolone with a starting dose of 15–25 mg/d for PMR and of 40–60 mg/d for GCA results in rapid improvement of symptoms. Fast-track clinics provide clinical and ultrasound examinations by experts within 24 hours. Their introduction led to a decrease of visual loss in GCA. The prednisolone dose can be discontinued within 1 year in about 50 % of GCA patients. Additional treatment with tocilizumab allows to reduce flares and decrease glucocorticoid doses. Tocilizumab is particularly useful in patients with relapses and with increased risk of glucocorticoid side effects.

Muskelschmerzen kommen häufig bei entzündlich-rheumatischen Erkrankungen vor und treten insbesondere bei der Polymyalgia rheumatica (PMR) auf. Die PMR kann mit der Riesenzellarteriitis (RZA) vergesellschaftet sein. Dieser Beitrag stellt den aktuellen Stand von Diagnostik und Therapie beider Erkrankungen vor.

Schlüsselwörter

Riesenzellarteriitis - Polymyalgia rheumatica - Ultraschall - Bildgebung - Tocilizumab

Key words

giant cell arteritis - polymyalgia rheumatica - ultrasound - imaging - tocilizumab

• Literatur

• 1 Jennette JC, Falk RJ, Bacon PA. et al 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 2013; 65: 1-11 . doi:10.1002/art.37715
• 2 Crowson CS, Matteson EL, Myasoedova E. et al The lifetime risk of adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases. Arthritis Rheum 2011; 63: 633-639 . doi:10.1002/art.30155
• 3 Park SJ, Kim HJ, Park H. et al Incidence, prevalence, mortality and causes of death in Takayasu Arteritis in Korea – A nationwide, population-based study. Int J Cardiol 2017; 235: 100-104 . doi:10.1016/j.ijcard.2017.02.086
• 4 Schmidt WA, Seifert A, Gromnica-Ihle E. et al Ultrasound of proximal upper extremity arteries to increase the diagnostic yield in large-vessel giant cell arteritis. Rheumatology (Oxford) 2008; 47: 96-101 . doi:10.1093/rheumatology/kem322
• 5 Dasgupta B, Cimmino MA, Maradit-Kremers H. et al 2012 provisional classification criteria for polymyalgia rheumatica. Ann Rheum Dis 2012; 71: 484-492 . doi:10.1136/annrheumdis-2011-200329
• 6 Schmidt WA. Polymyalgia rheumatica (PMR) und Riesenzellarteriitis (Arteriitis temporalis). In: Jung N, Mayet WJ, Mertens PR. Hrsg Rationelle Diagnostik und Therapie in der Inneren Medizin. 50. Lieferung. I.5.2. München: Elsevier, Urban & Fischer; 2019
• 7 Schmidt WA, Hartung W. Bildgebende Diagnostik bei Großgefäßvaskulitiden. Z Rheumatol 2019; 78: 847-858 . doi:10.1007/s00393-019-00711-3
• 8 Duftner C, Dejaco C, Sepriano A. et al Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and meta-analysis informing the EULAR recommendations. RMD Open 2018; 4: e000612 . doi:10.1136/rmdopen-2017-000612
• 9 Schmidt WA. The ultrasound halo sign of temporal arteries: is it always giant cell arteritis?. Rheumatology (Oxford) 2019; 58: 1898-1899 . doi:10.1093/rheumatology/kez355
• 10 Patil P, Williams M, Maw WW. et al. Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. Clin Exp Rheumatol 2015; 33 (Suppl. 89) 103-106
• 11 Diamantopoulos AP, Haugeberg G, Lindland A. et al The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment. Rheumatology (Oxford) 2016; 55: 66-70 . doi:10.1093/rheumatology/kev289
• 12 Dejaco C, Ramiro S, Duftner C. et al EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum 2018; 77: 636-643 . doi:10.1136/annrheumdis-2017-212649
• 13 Nielsen BD, Hansen IT, Kramer S. et al Simple dichotomous assessment of cranial artery inflammation by conventional 18F-FDG PET/CT shows high accuracy for the diagnosis of giant cell arteritis. Eur J Nucl Med Mol Imaging 2019; 46: 184-193 . doi:10.1007/s00259-018-4106-0
• 14 Robson JC, Kiran A, Maskell J. et al The relative risk of aortic aneurysm in patients with giant cell arteritis compared with the general population of the UK. Ann Rheum Dis 2015; 74: 129-135 . doi:10.1136/annrheumdis-2013-204113
• 15 Dejaco C, Singh YP, Perel P. et al 2015 Recommendations for the management of polymyalgia rheumatica. Ann Rheum Dis 2015; 74: 795-803 . doi:10.1136/annrheumdis-2015-207492
• 16 Buttgereit F, Brabant T, Dinges H. et al S3-Leitlinie zur Behandlung der Polymyalgia rheumatica. Z Rheumatol 2018; 77: 429-441 . doi:10.1007/s00393-018-0476-8
• 17 Hellmich B, Agueda A, Monti S. et al 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2020; 79: 19-30 . doi:10.1136/annrheumdis-2019-215672
• 18 Stone JH, Tuckwell K, Dimonaco S. et al Trial of tocilizumab in giant-cell arteritis. N Engl J Med 2017; 377: 317-328 . doi:10.1056/NEJMoa1613849
• 19 Adler S, Reichenbach S, Gloor A. et al Risk of relapse after discontinuation of tocilizumab therapy in giant cell arteritis. Rheumatology (Oxford) 2019; 58: 1639-1643 . doi:10.1093/rheumatology/kez091