Nielsen A W, Hemmig A K, de Thurah A, Schmidt W A, Sattui S E, Mackie S L, Brouwer E, Dejaco C, Keller K K, Mukhtyar C B
Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
Department of Rheumatology, University Hospital Basel, Basel, Switzerland.
Semin Arthritis Rheum. 2023 Dec;63:152260. doi: 10.1016/j.semarthrit.2023.152260. Epub 2023 Aug 22.
Prompt diagnosis and treatment of polymyalgia rheumatica (PMR) is crucial to prevent long-term complications and improve patient outcomes. However, there is currently no standardized approach to referral of suspected PMR patients to rheumatologists, leading to inconsistent management practices. The objective of this systematic review was to clarify the existing evidence regarding the following aspects of early management strategies in patients with suspected PMR: diagnostic strategies, GCA screening, glucocorticoid initiation prior to referral, value of shared care and value of fast track clinic.
Two authors performed a systematic literature search, data extraction and risk of bias assessment independently. The literature search was conducted in Embase, MEDLINE (PubMed) and Cochrane. Studies were included if they contained cohorts of suspected PMR patients and evaluated the efficacy of different diagnostic strategies for PMR, screening for giant cell arteritis (GCA), starting glucocorticoids before referral to secondary care, shared care, or fast-track clinics.
From 2,437 records excluding duplicates, 14 studies met the inclusion criteria. Among these, 10 studies investigated the diagnostic accuracy of various diagnostic strategies with the majority evaluating different clinical approaches, but none of them showed consistently high performance. However, 4 studies on shared care and fast-track clinics showed promising results, including reduced hospitalization rates, lower starting doses of glucocorticoids, and faster PMR diagnosis.
This review emphasizes the sparse evidence of early management and referral strategies for patients with suspected PMR. Additionally, screening and diagnostic strategies for differentiating PMR from other diseases, including concurrent GCA, require clarification. Fast-track clinics may have potential to aid patients with PMR in the future, but studies will be needed to determine the appropriate pre-referral work-up.
风湿性多肌痛（PMR）的及时诊断和治疗对于预防长期并发症及改善患者预后至关重要。然而，目前对于疑似PMR患者转诊至风湿病专家处尚无标准化方法，导致管理实践不一致。本系统评价的目的是阐明关于疑似PMR患者早期管理策略以下方面的现有证据：诊断策略、巨细胞动脉炎（GCA）筛查、转诊前启动糖皮质激素治疗、共享护理的价值以及快速通道诊所的价值。
两位作者独立进行系统文献检索、数据提取和偏倚风险评估。检索在Embase、MEDLINE（PubMed）和Cochrane中进行。如果研究包含疑似PMR患者队列，并评估了不同PMR诊断策略、巨细胞动脉炎（GCA）筛查、转诊至二级医疗机构前启动糖皮质激素治疗、共享护理或快速通道诊所的疗效，则纳入研究。
在排除重复记录后的2437条记录中，14项研究符合纳入标准。其中，10项研究调查了各种诊断策略的诊断准确性，大多数评估了不同的临床方法，但没有一项表现出始终如一的高性能。然而，4项关于共享护理和快速通道诊所的研究显示出有希望的结果，包括降低住院率、降低糖皮质激素起始剂量以及更快诊断PMR。
本评价强调了疑似PMR患者早期管理和转诊策略的证据稀少。此外，区分PMR与其他疾病（包括并发GCA）的筛查和诊断策略需要明确。快速通道诊所在未来可能有助于PMR患者，但需要进行研究以确定合适的转诊前检查。
