A national survey reveals wide variation in how clinicians diagnose, investigate, and manage polymyalgia rheumatica, strengthening calls for evidence-based care standards.
Australian rheumatologists remain divided on key aspects of polymyalgia rheumatica diagnosis, investigation and long-term management, according to a national survey that highlights persistent uncertainty around one of the most common inflammatory diseases affecting older adults.
The survey of 79 rheumatologists and trainees found substantial variation in views on atypical disease presentations, use of imaging, steroid-sparing therapy, and expected prognosis, despite broad agreement on initial glucocorticoid treatment strategies.
The findings, published in the Internal Medicine Journal, add weight to calls for standardised clinical care guidelines for PMR in Australia.
There is yet to be a gold-standard test to assist practitioners evaluating suspected cases of PMR, and in Australia, no medication is currently approved by the Therapeutic Goods Administration for the treatment of the disease.
Sarilumab, an interleukin-6 (IL-6) receptor blocker, became the first drug listed by the Food and Drug Administration (FDA) in the United States for the indication of relapsing PMR following the landmark SAPHYR trial, but has yet to gain TGA approval.
“Given there has been an increasing number of randomised controlled trials investigating novel therapeutic agents since that time, it seems probable that PMR’s antiquated treatment paradigm will soon be revised,” the researchers wrote.
“This study therefore aimed to delineate the current diagnostic and therapeutic approach of Australian rheumatologists and trainees to a suspected case of PMR.
“The results are intended to provide insights into the existing quality of care available to patients living with PMR and provide the basis for future development of a disease-specific clinical care standard.”
The landmark study was conducted by some of Australia’s most experienced and respected rheumatologists, including Dr Jessica Leung, Professor Claire Owen, Professor Catherine Hill, Australian Rheumatology Association president Adjunct Professor Helen Keen, Rheumatology Republic deputy editor Dr David Liew, Associate Professor Russell R.C. Buchanan, and Dr Jem Ninan.
Most respondents relied primarily on clinical assessment to diagnose PMR, with nearly 80% reporting they did not routinely order imaging.
However, almost three-quarters said imaging was valuable when diagnostic uncertainty arose, particularly for excluding alternative diagnoses, malignancy or concomitant giant cell arteritis (GCA).
Access to FDG-PET/CT emerged as a recurring frustration, with clinicians describing the modality as useful but often difficult to obtain.
The survey also exposed knowledge gaps around recognised but less typical PMR presentations.
While most clinicians accepted that peripheral joint involvement could occur in PMR, 13% believed symptoms affecting the hands or wrists excluded the diagnosis altogether, instead favouring seronegative rheumatoid arthritis.
About a third considered elevated inflammatory markers essential for diagnosis, despite evidence that a minority of patients present with normal ESR or CRP levels.
The researchers said these findings suggested many clinicians continued to view PMR as a relatively uniform disease with a classic presentation, despite growing evidence of broader clinical heterogeneity.
Management practices were more consistent. The median starting prednisolone dose was 15mg daily, with most clinicians favouring tapering by 2.5mg per month until 10mg was reached, followed by slower reductions.
However, approaches diverged once patients relapsed, with some clinicians returning to the last effective dose while others adjusted treatment according to symptom severity.
Almost every respondent reported prescribing a conventional synthetic DMARD as a steroid-sparing strategy, most commonly methotrexate.
Half estimated that at least a quarter of their PMR patients ultimately required such therapy, although 86% also acknowledged that the evidence supporting methotrexate remained inadequate.
Leflunomide was also commonly used despite the absence of randomised trial data.
The findings underscored a growing disconnect between traditional teaching and real-world clinical experience, the researchers noted.
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Although PMR has historically been regarded as a self-limiting condition responsive to glucocorticoids alone, survey respondents frequently described recurrent relapses, prolonged steroid exposure and significant treatment-related morbidity.
Steroid adverse effects were identified as the single biggest challenge facing patients, ahead of pain, stiffness, fatigue and sleep disturbance.
Physical therapy represented another area of inconsistency. About a quarter of clinicians reported never recommending exercise advice or allied health support, while a similar proportion incorporated these interventions into care for most patients.
The researchers noted this variation persisted despite guideline recommendations supporting exercise programs to maintain muscle function and reduce falls risk in older adults receiving long-term glucocorticoids.
Perhaps the most striking finding was the lack of consensus around prognosis.
Clinicians differed widely in their expectations of relapse rates and long-term remission, with 43% believing PMR comprised two distinct groups: patients whose disease resolved within two years and those who remained dependent on lifelong low-dose prednisolone.
There were several limitations to the study, the researchers said. They cautioned that the findings may not reflect broader PMR care because many patients are managed exclusively in primary care.
Survey responses were limited to rheumatologists and trainees and may over-represent more complex cases referred for diagnostic uncertainty, relapse or steroid-related complications. The possibility of selection bias also could not be excluded, as clinicians with a particular interest in PMR may have been more likely to participate.
However, the researchers said the survey reflected the evolving understanding of PMR as a chronic and often complex inflammatory disease rather than a uniformly benign condition.
They concluded that improved access to diagnostic imaging, better recognition of atypical presentations and the development of evidence-based clinical care standards could help reduce variability in patient care across Australia.
“In summary, this survey of the experience of Australian rheumatologists managing PMR has shed significant light on the complexities faced by clinicians in everyday clinical practice,” they wrote.
“Many responses challenged established perceptions of PMR as a benign and self-limiting condition, reflecting recent developments in our understanding of this common chronic rheumatic disease.
“There was broad agreement about the need for improved access to imaging in circumstances of diagnostic uncertainty and appropriate recognition of key priorities for patients.
“While good adherence to existing treatment recommendations was noted among respondents, the overall inadequacy of current management strategies remained abundantly clear.
“It is hoped that these insights will provide a starting point for future improvements in the standard of care available to patients living with PMR in Australia.”
