After glucose was controlled, patients experienced improvement in both symptoms and laboratory measures of polymyalgia rheumatica without glucocorticoid administration or an increase in glucocorticoid dosage, according to the report in the Annals of Internal Medicine.
"These findings were unexpected and are remarkable," write the authors, led by Dr. Ken Yoshida of The Jikei University School of Medicine, in Tokyo. "We believe that coincidental improvement is an unlikely explanation for these cases."
Polymyalgia rheumatica is a chronic inflammatory condition affecting elderly persons, the authors note in their report, and is characterized by severe pain and stiffness, mostly in the shoulders, upper arms, and pelvic girdle.
The researchers had no explanation for why controlling glucose levels might improve symptoms, but suggested that more research is in order.
"Treating polymyalgia rheumatica with glucocorticoid therapy is problematic," the authors write. "Most patients require at least one to two years of treatment, and too many patients develop adverse effects, such as diabetes mellitus, osteoporosis and hypertension. Therefore, we propose that a randomized controlled trial be considered to determine whether improved glycemic control, perhaps with meglitinide, might allow patients with type 2 diabetes and polymyalgia rheumatica to avoid glucocorticoid treatment."
The first case described by the researchers was a 68-year-old man with bilateral shoulder pain and morning stiffness. The patient, who fulfilled the 2012 European League Against Rheumatism/American College of Rheumatology provisional criteria for polymyalgia rheumatica had been taking NSAIDs for six weeks and had been receiving metformin to treat type 2 diabetes for five years. His labs showed: C-reactive protein (CRP) level, 62.9 mg/L (normal, <1.4 mg/L); hemoglobin mA1c (HbA1c) concentration, 7.9%; and fasting plasma glucose level, 8.88 mmol/L (160 mg/dL).
Before prescribing glucocorticoids, the researchers opted to first address his elevated glucose level by changing some of his antidiabetic medications and adding repaglinide, which improved his glycemic control. His polymyalgia rheumatica symptoms and laboratory findings improved considerably after just one week on the new regime and the biceps tenosynovitis initially detected on ultrasonography gradually resolved during the following year.
The second case involved a 72-year-old woman with bilateral shoulder pain, morning stiffness, bilateral hip pain and restricted hip mobility. She had been prescribed prednisolone, which did improve her symptoms, but when the dosage was tapered, the symptoms returned. When the researchers first saw her, she had a CRP level of 42.7 mg/L; an HbA1c concentration of 11.7%; and a postprandial glucose level of 18.6 mmol/L (335 mg/dL).
Instead of increasing the woman's prednisolone dosage, the researchers started the woman on repaglinide therapy that was later switched to mitiglinide to improve her glycemic control. During the next two weeks her symptoms improved.
The third case involved a 73-year-old man with bilateral shoulder and upper-arm pain, morning stiffness, and bilateral hip pain. The man, who fulfilled the criteria for polymyalgia rheumatica, had been using NSAIDs for five months without benefit. At that point, his labs showed a CRP level of 28 mg/L, and an HbA1c concentration of 6.7%. The researchers treated him with mitiglinide and pioglitazone. His glycemic control improved during the next two weeks, as did his symptoms and laboratory findings.
Dr. Yoshida did not respond to a request for comments.
While polymyalgia rheumatica is the second most common inflammatory autoimmune condition that affects the elderly, it's possible that one or two of the three patients might have something else, said Dr. Ashina Makol, an assistant professor in the division of rheumatology at the Mayo Clinic in Rochester, Minnesota. There are other disorders that could produce the same symptoms, she added.
Two of the three patients are in their 70s, which is the age at which the condition usually appears, Dr. Makol said. However, the most telling sign that a patient's symptoms are caused by polymyalgia rheumatica is a response to steroids and two of the patients described in the paper never got steroids.
And while the authors say that the patients fulfill the 2012 European League Against Rheumatism/American College of Rheumatology provisional criteria for polymyalgia rheumatica, those criteria were not developed as a diagnostic aid, but rather to assure that there would be homogenous groups of patients in clinical trials, Dr. Makol said.
Dr. Makol would like to see long-term follow-up on the three patients and would welcome a clinical trial, but, she said, "I don't know whether it would be feasible to do. Would one arm of the study not receive any treatment?"
By Linda Carroll
SOURCE: https://bit.ly/2H5fn9G Annals of Internal Medicine, online September 15, 2020.
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