今日の臨床サポート

リウマチ性多発筋痛症

著者: 小林知志 杏林大学医学部付属病院 腎臓・リウマチ膠原病内科

監修: 岸本暢将 杏林大学医学部 腎臓・リウマチ膠原病内科

著者校正済:2021/11/24
現在監修レビュー中
参考ガイドライン:
  1. 欧州リウマチ学会(EULAR)/米国リウマチ学会(ACR):2015 recommendations for the management of polymyalgia rheumatica: European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015 Oct;74(10):1799-807.
  1. 欧州リウマチ学会(EULAR)/米国リウマチ学会(ACR):provisional Classification Criteria for Polymyalgia Rheumatica : A European League Against Rheumatism/American College of Rheumatology Collaborative Initiative. Arthritis Rheum. 2012 Apr;64(4):943-54.
患者向け説明資料

概要・推奨   

  1. PMRを疑う場合、赤沈値(ESR)とCRPを測定することは強く推奨される(推奨度1)。
  1. PMRの初期治療には少量のステロイドが強く推奨される。なお、投与の際には通常15mg/日より開始。1週後の再診時50%以上の改善がなければ他の鑑別疾患を考慮する。他の疾患が除外されれば20mg/日に増量も可能である(推奨度1)。
  1. ステロイド製剤を3カ月以上内服する予定の患者では、骨粗鬆症の予防として1日にカルシウム1200mg、ビタミンD800IUを食事あるいはサプリメントで継続的に摂取することが推奨される(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小林知志 : 未申告[2021年]
監修:岸本暢将 : 講演料(中外製薬,日本イーライリリー,ノバルティス,ヤンセンファーマ,ユーシービージャパン,田辺三菱製薬,アッヴィ合同会社,エーザイ(株),ブリストル・マイヤーズスクイブ(株),ギリアド・サイエンシズ(株))[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 50歳以上の高齢者で、急性~亜急性に発症し、遷延する四肢近位筋主体の筋痛症状があり、赤沈、CRP上昇を認める場合、本疾患を思い浮かべる。
  1. 全身倦怠感、食思不振、微熱、体重減少、抑うつ傾向などの筋骨格系以外の症状が発症早期からみられる。
  1. PMRに特異的な検査所見はない。確定診断を下すには除外診断を経る必要がある。
  1. PMRの10~20%にGCA巨細胞性動脈炎(側頭動脈炎)が合併する。
  1. 38℃を越える高熱はPMR単独ではまれ。GCA巨細胞性動脈炎を合併すると高熱がでる。
  1. 治療的診断として少量のステロイド(プレドニゾロン換算で10~15mg/日程度)が劇的に奏功する。
病歴・診察のポイント  
  1. 項部、肩甲部、腰部、臀部、大腿部などの対称性の筋肉痛とこわばりが主症状で、遷延すると貧血、体重減少が現れる。

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文献 

著者: F Cantini, C Salvarani, I Olivieri, L Macchioni, A Ranzi, L Niccoli, A Padula, L Boiardi
雑誌名: Semin Arthritis Rheum. 2000 Aug;30(1):17-24. doi: 10.1053/sarh.2000.8366.
Abstract/Text OBJECTIVE: To determine the frequency and clinical features of patients with polymyalgia rheumatica (PMR) and normal erythrocyte sedimentation rate (ESR) at diagnosis or during relapse/recurrence. To evaluate the usefulness of C-reactive protein (CRP) and ESR in the assessment of PMR activity.
METHODS: A prospective follow-up study on 177 consecutive patients meeting the criteria for PMR diagnosed over a 5-year period was conducted in two Italian secondary referral centers of rheumatology. At diagnosis and during follow-up, ESR (Westergren method) and CRP (nephelometry) were measured in all patients. Phenotypic analysis of lymphocyte subpopulations was performed on 78 PMR patients at diagnosis. A two-color technique using the association of specific monoclonal antibodies was applied. A control group consisting of 18 healthy adults older than 60 years was matched for age and sex with the PMR patients.
RESULTS: Ten of 177 (6%) patients had normal ESR values at diagnosis (< or = 30 mm/h). Patients with normal ESR were predominantly men and had lower CRP levels; systemic signs and symptoms were more frequent in patients with higher ESR. The percentages of circulating CD8+ cells were similar in the two groups. CRP values at diagnosis were normal in only 2 of 177 (1%) patients. CRP values were elevated in 9 of 10 patients with normal ESR at diagnosis. Twenty-five episodes of relapse/recurrence with normal ESR occurred in 17 patients. CRP was high in 62% of these episodes. Results of univariate analysis indicated that the 10th percentile for ESR (40 mm/h) and the 70th percentile for CRP (7.8 mg/dL) values at diagnosis were the best cutoff points that discriminate between patients with and without relapse/recurrence. Cox proportional hazards modeling showed that ESR greater than 40 mm/h and CRP greater than 7.8 mg/dL at diagnosis were the two variables that independently increased the risk of relapse/recurrence. However, the relative risk related to ESR was twice than that related to CRP (4.9 vs 2.1).
CONCLUSION: PMR with a normal ESR at diagnosis was infrequent in our study compared with previous studies. ESR was a superior predictor of relapse than CRP. However, CRP was a more sensitive indicator of current disease activity.

PMID 10966209  Semin Arthritis Rheum. 2000 Aug;30(1):17-24. doi: 10.10・・・
著者: H A Bird, B F Leeb, C M Montecucco, N Misiuniene, G Nesher, S Pai, C Pease, J Rovensky, B Rozman
雑誌名: Ann Rheum Dis. 2005 Apr;64(4):626-9. doi: 10.1136/ard.2004.025296.
Abstract/Text OBJECTIVE: To compare the performance of the several different diagnostic criteria sets currently in use for polymyalgia rheumatica (PMR).
METHODS: 213 patients attending eight rheumatological centres in eight different European countries were studied. All had recently been referred and were considered by the senior investigator at each centre, selected because of their experience in treatment of PMR, to have this condition. By use of a standard international proforma, the requisite diagnostic points in each criteria set were sought. Sensitivity for each criterion from each set was then calculated, as well as the sensitivity of each criteria set as a whole.
RESULTS: Of four criteria sets compared, the Bird (1979) criteria performed best with a sensitivity of 99.5%, and the Hunder (1982) criteria second best, with sensitivity of 93.3%. These both performed significantly better than the two other criteria sets, though each of these was admittedly developed for rather specialised reasons.
CONCLUSIONS: Although this study compares homogeneity, we suggest the Bird 1979 or Hunder 1982 criteria should be used whenever possible. Studies that have used alternative criteria may have less sensitivity in diagnosis.

PMID 15769919  Ann Rheum Dis. 2005 Apr;64(4):626-9. doi: 10.1136/ard.2・・・
著者:
雑誌名: Arthritis Rheum. 2010 Oct;62 Suppl 10:1. doi: 10.1002/art.30166.
Abstract/Text
PMID 21204100  Arthritis Rheum. 2010 Oct;62 Suppl 10:1. doi: 10.1002/a・・・
著者: José Hernández-Rodríguez, Maria C Cid, Alfons López-Soto, Georgina Espigol-Frigolé, Xavier Bosch
雑誌名: Arch Intern Med. 2009 Nov 9;169(20):1839-50. doi: 10.1001/archinternmed.2009.352.
Abstract/Text BACKGROUND: Polymyalgia rheumatica (PMR) treatment is based on low-dose glucocorticoids. Glucocorticoid-sparing agents have also been tested. Our objective was to systematically examine the peer-reviewed literature on PMR therapy, particularly the optimal glucocorticoid type, starting doses, and subsequent reduction regimens as well as glucocorticoid-sparing medications.
METHODS: We searched Cochrane Databases and MEDLINE (1957 through December 2008) for English-language articles on PMR treatment (randomized trials, prospective cohorts, case-control trials, and case series) that included 20 or more patients. All data on study design, PMR definition criteria, medical therapy, and disease outcomes were collected using a standardized protocol.
RESULTS: Thirty studies (13 randomized trials and 17 observational studies) were analyzed. No meta-analyses or systematic reviews were found. The PMR definition criteria, treatment protocols, and outcome measures differed widely among the trials. Starting prednisone doses higher than 10 mg/d were associated with fewer relapses and shorter therapy than were lower doses; starting prednisone doses of 15 mg/d or lower were associated with lower cumulative glucocorticoid doses than were higher starting prednisone doses; and starting prednisone doses higher than 15 mg/d were associated with more glucocorticoid-related adverse effects. Slow prednisone dose tapering (<1 mg/mo) was associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens. Initial addition of oral or intramuscular methotrexate provided efficacy at doses of 10 mg/wk or higher. Infliximab was ineffective as initial cotreatment.
CONCLUSIONS: The scarcity of randomized trials and the high level of heterogeneity of studies on PMR therapy do not allow firm conclusions to be drawn. However, PMR remission seems to be achieved with prednisone treatment at a dose of 15 mg/d in most patients, and reductions below 10 mg/d should preferably follow a tapering rate of less than 1 mg/mo. Methotrexate seems to exert glucocorticoid-sparing properties.

PMID 19901135  Arch Intern Med. 2009 Nov 9;169(20):1839-50. doi: 10.10・・・
著者: L M Buckley, E S Leib, K S Cartularo, P M Vacek, S M Cooper
雑誌名: Ann Intern Med. 1996 Dec 15;125(12):961-8.
Abstract/Text BACKGROUND: Therapy with low-dose corticosteroids is commonly used to treat allergic and autoimmune diseases. Long-term use of corticosteroids can lead to loss of bone mineral density and higher risk for vertebral fractures. Calcium and vitamin D3 supplementation is rational therapy for minimizing bone loss, but little evidence for its effectiveness exists.
OBJECTIVE: To assess 1) the effects of supplemental calcium and vitamin D3 on bone mineral density of patients with rheumatoid arthritis and 2) the relation between the effects of this supplementation and corticosteroid use.
DESIGN: 2-year randomized, double-blind, placebo-controlled trial.
SETTING: University outpatient-care facility.
PATIENTS: 96 patients with rheumatoid arthritis, 65 of whom were receiving treatment with corticosteroids (mean dosage, 5.6 mg/d).
INTERVENTION: Calcium carbonate (1000 mg/d) and vitamin D3 (500 IU/d) or placebo.
MEASUREMENTS: Bone mineral densities of the lumbar spine and femur were determined annually.
RESULTS: Patients receiving prednisone therapy who were given placebo lost bone mineral density in the lumbar spine and trochanter at a rate of 2.0% and 0.9% per year, respectively. Patients receiving prednisone therapy who were given calcium and vitamin D3 gained bone mineral density in the lumbar spine and trochanter at a rate of 0.72% (P = 0.005) and 0.85% (P = 0.024) per year, respectively. In patients receiving prednisone therapy, bone mineral densities of the femoral neck and the Ward triangle did not increase significantly with calcium and vitamin D3. Calcium and vitamin D3 did not improve bone mineral density at any site in patients who were not receiving corticosteroids.
CONCLUSION: Calcium and vitamin D3 prevented loss of bone mineral density in the lumbar spine and trochanter in patients with rheumatoid arthritis who were treated with low-dose corticosteroids.

PMID 8967706  Ann Intern Med. 1996 Dec 15;125(12):961-8.
著者: J Homik, A Cranney, B Shea, P Tugwell, G Wells, R Adachi, M Suarez-Almazor
雑誌名: Cochrane Database Syst Rev. 2000;(2):CD001347. doi: 10.1002/14651858.CD001347.
Abstract/Text OBJECTIVES: To assess the effects of bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis.
SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group trials register, Medline up to 1997 and Embase1988-1997), and selected hand searching of reference lists was conducted. Hand searching of scientific abstracts from relevant meetings for the last five years was also done. An electronic search in Current Contents was done for the last six months. The Cochrane Controlled Trials Register (CCTR) will be searched for future updates. All languages were included in the search. For practical reasons only those in English were included, but all languages will be retrieved and translated for future updates.
SELECTION CRITERIA: All controlled clinical trials (CCTs) dealing with prevention or treatment of corticosteroid-induced osteoporosis with bisphosphonates of any type and reporting the outcomes of interest were assessed. Trials had to involve adults only, and subjects had to be taking a mean steroid dose of 7.5 mg/day or more.
DATA COLLECTION AND ANALYSIS: All data extraction was performed by two independent reviewers. Outcomes of interest included change in bone mineral density (BMD) at the lumbar spine and femoral neck at six and 12 months. If present, data on number of new fractures and withdrawals due to adverse effects were also extracted. All data extraction was performed by two independent reviewers. Both continuous and dichotomous data were analyzed using fixed effects models. When significant heterogeneity was present, a random effects model was used.
MAIN RESULTS: A total of 13 trials, including 842 patients are included in this meta-analysis. Results are reported as a weighted mean difference of the percent change in BMD between the treatment and placebo groups, with trials being weighted by the inverse of their variance. The 95% confidence intervals (95% CI) are presented. At the lumbar spine, the weighted mean difference of BMD between the treatment and placebo groups was 4.3% (95% CI 2.7, 5.9). At the femoral neck, the weighted mean difference was 2.1% (95%CI 0. 01, 3.8). Although there was a 24% reduction in odds of spinal fractures [OR 0.76 (95%CI 0.37, 1.53)], this result was not statistically significant.
REVIEWER'S CONCLUSIONS: Bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. Efficacy regarding fracture prevention cannot be concluded from this analysis, although bone density changes are correlated with fracture risk.

PMID 10796432  Cochrane Database Syst Rev. 2000;(2):CD001347. doi: 10.・・・

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