Sobrero A, Manzo C, Stimamiglio A. The role of the general practitioner and the out-of-hospital public rheumatologist in the diagnosis and follow-up of patients with polymyalgia rheumatica. Reumatismo. 2018; 70: 44–50.
At a glance
The proposed study is a review of the literature on the role of the general practitioner (GP) and the territorial rheumatologist in the management of patients with rheumatic polymyalgia. The review shows that, although rheumatic polymyalgia is a common clinical manifestation in the elderly, the diagnostic accuracy on the territory is not optimal; according to some data, up to a quarter of patients initially classified as rheumatic polymyalgia receive a different diagnosis after specialist reassessment. The review therefore focuses on the definition of clinical features that suggest the need for early patient referral to rheumatological evaluation in order to avoid diagnostic misclassifications.
What is already known
Rheumatic polymyalgia is a common inflammatory manifestation of adult-elderly inflammation that manifests itself with the acute/subacute onset of pain and symmetrical stiffness in the shoulders and/or hips, in association with increased inflammatory indexes and constitutional symptoms. The diagnosis is fundamentally clinical and must take into account the exclusion of many conditions that can mimic a rheumatic polymyalgia.
The GP is often the first doctor to evaluate patients with a new onset of rheumatic polymyalgia and often, in light of the severity of the symptoms and the potential expectation for a specialist evaluation, is called upon to make an initial diagnostic evaluation and initiate a first line of treatment. However, up to 20% of patients may present an atypical onset that can make the diagnosis more complex.
In addition, rheumatic polymyalgia responds well to steroid therapy, so that a diagnostic re-evaluation after starting therapy is often complicated.
Design and Method
Non-systematic literature review.
Rheumatic polymyalgia is often diagnosed and managed by the GP, however, according to some cases, the diagnostic accuracy is not optimal with a proportion of up to 25% of patients who are subsequently diagnosed with another clinical condition. This can have important consequences, resulting from the failure to diagnose diseases that can sometimes be very severe; it can also cause prolonged and inappropriate exposure to steroid treatment.
Current guidelines suggest to refer patients to specialist evaluation in case of atypical clinical manifestations, such as: normal or excessively high phlogosis indexes, atypical symptoms (age at onset <60 years, chronic onset, lack of shoulder involvement), poor response to steroid therapy, presence of important systemic symptoms.
In the case of typical manifestations, the literature suggests that the GP may decide to start steroid therapy, while therapy with analgesics and anti-inflammatory drugs should be reserved for the initial stages before the diagnosis is established.
According to current guidelines the attack dose should be for most patients between 12.5 and 25 mg/day of prednisone, to be reduced over 4-8 weeks to 10 mg/day and then further decreased by 1-1.25 mg per month until complete suspension. In case of relapse it is indicated to restore the minimum effective steroid dose for 4-8 weeks.
The review highlights how current studies document a very good agreement in the definition of recidivism between specialists and GPs, suggesting a central role of the GP in patient follow-up.
Finally, the review points out that in Italy, the presence of the “territorial” rheumatologist, outside the hospital, represents a peculiarity compared to other European countries, representing a potential reference point for sharing more complex cases with the GP.
The main element of interest of the presented study is that the authors took stock of the role of the GP in the management of rheumatic polymyalgia. The clinical relevance of this is high, especially considering the fairly high prevalence of rheumatic polymyalgia in the general population and the risk that misdiagnosis may delay the identification of alternative clinical conditions that may sometimes put the patient’s life at risk. The authors, from the review of the literature, suggest a direct management of the GP in typical cases, identifying the elements of atypia that should suggest an evaluation, at least preliminary to the final diagnostic definition, by a specialist.
The work presented is a review, therefore it lacks original data; moreover, the data related to the role of the GP are mainly derived from studies conducted in other countries, a factor that does not make the conclusions automatically extend to the Italian reality, especially if we consider the differences related to the role of the GP in the various European countries.
By Mattia Bellan