Highlights from the European Congress of Internal Medicine

A CT exam is also useful if there’s strong suspicion of GCA, she added. She cited the 2021 EULAR/ACR classification criteria for PMR, which include being 50 years or older with bilateral shoulder pain not explained by other pathology, morning stiffness lasting more than 45 minutes, an elevated C-reactive protein or erythrocyte sedimentation rate, and new hip pain.⁵

Late-onset rheumatoid arthritis (RA) can mimic PMR, particularly because RA can present with symptoms of PMR, said Dr. Cipriano. Because of this, all patients with PMR should be screened for RA antibodies.

PMR can also be an immune-related adverse event in about 5% of patients using immune checkpoint inhibitors, she said. The majority of these patients respond well to treatment with glucocorticoids. EULAR’s 2021 statement regarding the diagnosis and management of people who develop rheumatic adverse events from cancer immunotherapy with checkpoint inhibitors is instructive, she added.⁶

Dr. Cipriano also addressed the link between PMR and malignancies. Although not every patient with PMR needs to be screened for malignancies, she said that patients who do not respond to therapy should be checked.

Most PMR patients respond well to glucocorticoids—typically a slowly tapered, 12 mg to 25 mg dose of prednisone or equivalent. It’s important to be aware of comorbidities or risk factors that can lead to adverse events.

“If disease flare-up occurs, we can increase the pre-relapse dose and slow the tapering. If we have patients who are contraindicated for long-term therapy with steroids or who can develop adverse events related to therapies, the indication is to start immunosuppressive drugs early,” Dr. Cipriano said. Most commonly, this will be methotrexate.

Autoimmune Testing

In her presentation, Pitfalls of Autoimmune Serological Markers, Chiara Bellocchi, MD, PhD, shared indications that a patient requires serological testing and questions to help determine if a patient has rheumatic disease.

Dr. Bellocchi

Dr. Bellocchi is a researcher in the Department of Clinical and Community Sciences, University of Milan, and clinical immunologist, Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. Here are a few pearls she shared:

• About 10–20% of the population will test positive for anti-nuclear antibodies. Their presence could be normal but could also indicate future autoimmune disease. It’s often a useful first test for suspected connective tissue disease or idiopathic inflammatory myopathies;
• Anti-dsDNA is highly specific to SLE and presents in fewer than 2% of other autoimmune diseases. However, patients with drug-induced lupus will test negative for anti-dsDNA;
• Low levels of C3 or C4 may indicate an immune-complex disease, such as SLE or vasculitis;

Questions to help diagnose connective tissue disease: