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This paper aims to examine the relationship between different characteristics of pain and stiffness and the functional status of patients with newly diagnosed polymyalgia rheumatica (PMR). Baseline analysis of an inception cohort study was conducted. Patients aged ≥18 years, with a new diagnosis of PMR were recruited from 382 English general practices. Participants were mailed a baseline questionnaire, including separate pain and stiffness manikins and numerical rating scales (NRS), a question on their ability to raise their arms above their head and the modified Health Assessment Questionnaire (mHAQ) to examine participants’ functional status. Linear regression analysis, reported as regression co-efficients (95% confidence intervals (95% CI)), was used to assess the association of pain and stiffness with function, initially unadjusted and then adjusted for age, gender, deprivation status, smoking status, BMI, anxiety and depression. Six hundred fifty two patients responded to the baseline survey (88.5%). The majority (88.2%) reported no, or mild impairment in their functional status. Adjusted linear regression analysis demonstrated that high (NRS ≥8) pain (0.20 (95% CI 0.10–0.28)) or stiffness (0.18 (0.09–0.26)) ratings, an increasing number of sites of pain (0.18 (0.06–0.29)) or stiffness (0.19 (0.08–0.31)) and shoulder pain (0.18 (0.05–0.31)), stiffness (0.10 (0.01–0.20)) and difficulty raising arms above one’s head (0.19 (0.10–0.28)) were all associated with increased functional impairment. The majority of newly diagnosed PMR patients reported no or minimal functional difficulty. However, those who experience severe or widespread pain or stiffness often have significant functional limitation in performing their daily activities and may be a subset worthy of additional focus in primary care.

Background Gout is the most common type of inflammatory arthritis, affecting 2.4% of adults in the UK and is associated with a number of co-morbidities. Our understanding of the association between gout and fracture risk is limited with previous studies offering conflicting results. Objectives To determine the risk of fracture among gout patients and assess the potential impact of urate-lowering therapy (ULT) on fracture risk. Methods Utilising primary care records from Clinical Practice Research Datalink we identified patients with gout between 1990 and 2004 who were followed up until 2015. Each gout patient was individually matched to 5 individuals without gout based on age, sex, and registered practice. Absolute rate (AR) of fracture and hazard ratios (HR) were calculated using Cox regression models. We further stratified our analysis by age, gender and ULT prescription. Results We matched 35,857 patients with incident gout to 148,407 controls. Overall, we found no increased risk of fracture among gout patients compared to controls. However, men with no evidence of ULT had higher absolute risk of fracture compared to controls (AR=39 versus 26 per 10,000 person-years) corresponding to a 23% (HR=1.23; 95% CI 1.12–1.36) increased risk. The risk was particularly high for vertebral (HR=1.50; 95% CI 1.20–1.87) and wrist fracture (HR=1.45; 95% CI 1.21–1.74). Those treated with ULT had a 12% (HR=0.88; 95% CI 0.79–0.98) lower risk of fracture. Similar findings were not observed for women. Conclusions We found higher risk of vertebral and wrist fractures among men with gout not prescribed ULT. Those prescribed ULT had lower risk of fracture compared to the general population. Further research is needed to understand the role of ULT in fracture prevention. Acknowledgements CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice. TH is funded by a NIHR Clinical Lectureship in General Practice and AAS is funded by NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health Disclosure of Interest None declared

Background Psoriasis is a common inflammatory skin disease affecting 2–4% of the population and of these a subset will develop an associated inflammatory arthritis (psoriatic arthritis - PsA). An increased risk of osteoporosis has previously been reported in psoriasis patients but the risk of fracture in patients with both psoriasis and PsA has not been established. Objectives To estimate the effect of psoriasis, and PsA, on the risk of fracture using a large electronic primary health care database. Methods A matched cohort study was conducted utilizing data from the Clinical Practice Research Datalink, a large UK database of primary care medical records. The exposed population was defined as psoriasis patients aged over 40 years with an incident diagnosis between 1990–2004, who were followed up until 2015. Four unexposed patients were matched to each exposed based on age, sex and general practice. The incidence rate of fracture were calculated as the number of incident diagnoses per 10,000 person-years, stratified by sex. Hazard ratios (HR) and 95% confidence intervals were estimated using a Cox proportional hazards model to compare the hazard rate between the exposed and unexposed, adjusting for BMI, alcohol consumption, smoking status, Charlson comorbidity index and steroid use. Fracture risk was estimated for patients with both psoriasis and PsA, identified as patients with an incident diagnosis of psoriasis and a diagnosis of PsA between 1990–2004. Results 24,219 patients with psoriasis and 94,820 controls were included in the study. The mean age was 59 years at study entry and just over half (51%) of the patients were male. The incidence rate of fracture was 58.4 (95% CI:55.6–61.3) and 53.1 (51.7–54.5) per 10,000 person-years for the exposed and unexposed, respectively. After adjusting for confounding factors, patients with psoriasis had 12% increased risk of fracture (HR: 1.12; 95% CI: 1.06–1.19) compared to the matched unexposed group. The risk was slightly higher in males (1.22 (1.09–1.36)) than females (1.09 (1.03–1.17)). Among those with psoriasis, 4.1% were also diagnosed with PsA. An increased risk of 45% was found in those exposed to both psoriasis and PsA compared to the unexposed group (1.45 (1.09–1.94)). Conclusions This study reports for the first time, an increase in fracture risk in patients with psoriasis. A higher risk was found in males than females and the risk was further increased if the patient also had PsA. These findings suggest that fracture risk assessment needs to be considered for individuals with psoriasis and PsA. Acknowledgements This study was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). TH is funded by an NIHR Clinical Lectureship in General Practice. AAS is funded by an NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest None declared

Background Early, accurate diagnosis of RA is critical to improving outcomes. Patients with RA may develop a variety of symptoms including joint pain, swelling and stiffness. The Symptoms in Persons at Risk of Rheumatoid Arthritis (SPARRA) questionnaire was derived to assess the presence, severity and impact of common symptoms in patients at risk of RA (1). However, to date there is little data available on how common these symptoms are in primary care consulters. Objectives To describe the prevalence of self-reported inflammatory joint symptoms in primary care patients consulting for both musculoskeletal and non-musculoskeletal complaints. Methods Questionnaires were sent to 10161 individuals, of whom 5050 had consulted primary care for musculoskeletal problems. The remainder were matched to this sample by age, gender and general practice and had consulted for any non-musculoskeletal indication. Respondents provided data on presence of common symptoms such as joint pain, stiffness and swelling. The prevalence of these symptoms, their severity and impact was compared between musculoskeletal and non-musculoskeletal consulters. Results 4549 people responded to the survey (adjusted response 45.8%) of whom 52.3% were in the musculoskeletal consultation group. The mean (SD) age was 61.6 (14.8) years and 58.9% were female. Symptoms commonly associated with inflammatory arthritis were common in both groups. 89.1% of musculoskeletal consulters reported current joint pain, compared with 74.9% in the non-MSK consulter group, 48.7% of MSK consulters reported joint swelling compared to 37.3% of non-MSK consulters and 77.9% of MSK consulters reported joint stiffness (64.3% in non-MSK group). A similar proportion in each group reported fatigue (59.5% vs 55%). Joint symptoms remained common symptoms in both groups even when severity and impact of symptoms was considered. Conclusions Although symptoms such as joint pain, swelling, and stiffness are predictive of inflammatory arthritis, a large proportion of those consulting primary care for non-musculoskeletal reasons routinely report these symptoms when prompted. This compounds the challenges of diagnosing inflammatory arthritis in a non-specialist setting where new approaches are needed to ensure accurate, early diagnosis, facilitating a treat to target approach. References van Tuyl, et al. Musculoskeletal Care 2016;14:169–73. Acknowledgements This study represents independent research funded by the National Institute for Health Research (NIHR). TH is funded by a NIHR Clinical Lectureship in General Practice. CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). The views expressed are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health. Disclosure of Interest None declared

Background Polymyalgia rheumatica (PMR) is a common rheumatological disorder of older patients. The majority of UK patients are diagnosed and managed exclusively in general practice. In primary care, it has been shown that there is wide variation in practice, and established diagnostic criteria are infrequently used. Aim This study aims to investigate the diagnostic processes, management, and monitoring of patients with PMR in UK primary care. Design and setting This is a retrospective cohort study set in primary care. Method Data were extracted from two interlinked primary care databases from north Staffordshire. Patients with PMR were identified using Read Codes and the relevant investigation, prescription, and consultation data were extracted and reviewed. Results Three hundred and four patients’ records were analysed. Documentation of symptoms leading to a diagnosis of PMR was found in 248 records (81.6%). A documented process of exclusion of relevant differential diagnoses was demonstrated in 68 (22.4%) patients. The mean initial dose of prednisolone was 21.5 mg. Referral to specialist care was made for 135 (44.4%) patients. Gastric prophylaxis was prescribed in 85 (28.0%) cases. Osteoporosis prophylaxis was prescribed to 183 patients (60.2%); 12 patients (3.9%) developed osteoporosis and 56 (18.4%) developed gastric symptoms that led to GP consultation. Conclusion The management of PMR in general practice could be optimised. Identified areas for improvement include clear documentation of a process of exclusion of other diagnoses, and prophylaxis for potential treatment complications, including osteoporosis and gastric symptoms.

The authors describe the causes, diagnosis and recommended management of polymyalgia rheumatica, the commonest rheumatological disorder in the elderly.

BACKGROUND: The aim was to characterise the sociodemographic, general health and polymyalgia rheumatica (PMR)-specific features of participants in a large inception cohort of patients with PMR diagnosed in UK primary care. METHODS: Patients (n = 739) with a new diagnosis of PMR were referred into the study and mailed a questionnaire detailing their general health and sociodemographic characteristics in addition to the symptoms of and treatment for PMR. Characteristics of responders and non-responders were compared and descriptive statistics were used to characterise the health of the cohort. RESULTS: A total of 654 individuals responded to the questionnaire (adjusted response 90.1 %). Responders and non-responders were similar in age, gender and deprivation (based on postcode). The mean (standard deviation) age of the recruited cohort was 72.4 (9.3) years; 62.2 % were female. The sample reported high levels of pain and stiffness (8 out of 10 on numerical rating scales) and reported stiffness that lasted throughout the day. High levels of functional impairment, fatigue, insomnia and polypharmacy were also reported. Overall, women reported worse general and PMR-specific health than did men. CONCLUSIONS: This first primary care cohort of patients with incident PMR is similar in demographic terms to cohorts recruited in secondary care. However, the extent of symptoms, particularly reported stiffness, is higher than has been described previously. Given the majority of patients with PMR are exclusively managed in primary care, this cohort provides important information on the course of PMR in the community that will help clinicians managing this painful and disabling condition.

Background: Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events. Methods: We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica. Results: A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis. Interpretation: Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.

Musculoskeletal disorders such as back pain, neck pain, osteoarthritis, and rarer conditions like gout and inflammatory arthritis are the most common limiting long-term conditions in the UK.1 They represent a huge and growing burden on population health, accounting for 30% of all years lived with disability, and 7.5 million days lost from work each year. The challenge was recognised by the Chief Medical Officer and confirmed in the recent Global Burden of Disease report: ‘Although health-care cost and activity data confirm that these conditions consume massive UK health system resources, concerted public health and high-quality integrated medical care strategies are not implemented systematically. Interventions are available for musculoskeletal disorders, but to what extent the health system is delivering is unclear. Musculoskeletal disorders will only increase in importance in view of present trends and require more urgent policy attention.’ 1 General practice and primary care more generally have a critical role in meeting these challenges. Of the 300 million general practice consultations that occur in England every year, approximately one in six are for arthritis and musculoskeletal problems. An important feature of primary care is its capacity to address the needs of patients with long-term conditions such as musculoskeletal complaints; this includes responsibility for anticipatory and preventive care across the life-course, supporting patients to self-manage their condition, and delivery of evidence-based clinical treatment. Effective primary health care can improve the health and wellbeing of individual patients and their families, and reduce the health and economic impact of musculoskeletal disorders on the population as a whole. The Research Institute for Primary Care and Health Sciences at Keele University is a multidisciplinary collaboration between academics from general practice, clinical rheumatology, epidemiology, physiotherapy, psychology, and health services research, and clinical partners across the West Midlands and Cheshire. …

Objective To investigate the incidence of new cancer diagnoses in a community sample of patients with polymyalgia rheumatica (PMR). Methods All incident cases of PMR in the UK General Practice Research Database (GPRD) (1987–99), without pre-existing cancer or vascular disease and treated with corticosteroids (n=2877) were matched with up to five age, sex and GP practice patients without PMR (n=9942). Participants were followed up until first cancer diagnosis, death, transfer out of the database or end of available records. Results The mean age of the sample was 71.6 years (SD 9.0), 73% were female. Median follow-up time was 7.8 years (IQR 3.4, 12.3). 667 (23.2%) people with a PMR diagnosis developed cancer compared with 1938 (19.5%) of those without PMR. There was an interaction between PMR status and time. In the first 6 months after diagnosis, those with a PMR diagnosis were significantly more likely to receive a cancer diagnosis (adjusted HR (95% CI): 1.69 (1.18 to 2.42)). The number of events was small, but occurrences of prostate, blood, lymph nodes, female reproductive and nervous system cancers may be more common in those with PMR in the first 6 months after PMR diagnosis. Conclusions An increase in the rate of cancer diagnoses was noted in the first 6 months of observation, but we were unable to determine whether the cancer incidence in PMR was different from controls, beyond this time point. Clinicians should ensure they fully exclude cancer as a cause of PMR-like symptoms and monitor patients for possible malignancies.

Polymyalgia rheumatic (PMR) is the most common inflammatory arthritis managed in primary care settings. The majority of clinical care is typically provided by General Practitioners (GPs) with evidence suggesting that current management is suboptimal. This talk will highlight some of the key challenges faced by GPs highlighting areas where the diagnosis, monitoring and long term care can be improved. Disclosure of Interest None declared

Background Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition. Methods Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers. Discussion This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disorder affecting older people.1 Patients typically present with bilateral shoulder pain, morning stiffness, raised inflammatory markers, and have a rapid response to low-dose corticosteroids. There is no gold standard diagnostic test and despite being first described in 1888, controversies still exist as to its defining characteristics. PMR carries a lifetime risk of 2.4% for females and 1.7% for males.2 The incidence in the UK has been shown to be 8.42 per 10 000 person years.3 In the UK, the majority of patients are managed exclusively in primary care4 with an average full-time GP seeing five new cases of PMR per year.5 Accurate diagnosis can be challenging even for specialists, but is essential as many serious illnesses can mimic PMR. Guidelines for the diagnosis and management of PMR have recently been published by the British Society of Rheumatologists (BSR) and British Health Professionals in Rheumatology (BHPR).6 Consider PMR in patients over the age of 50 years with: Subsequent clinical assessment and investigations should …

Background Giant Cell Arteritis (GCA) is the commonest large vessel vasculitis yet a full time UK general practitioner (GP) can expect to see just 1 case every 1-2 years [Barraclough]. GCA may be difficult to identify, particularly in atypical cases. For example headache has been shown to be absent in just under a quarter of GCA patients which may falsely reassure clinicians resulting in delayed diagnosis and potential visual loss [Ezeonyeji]. Objectives The aim of this study was to investigate how GPs identify GCA. Methods A postal questionnaire survey of 5000 randomly selected UK general practitioners was undertaken. Questions included experience of managing patients with GCA, presenting symptoms used to identify GCA and the referral pathways used. Results 1249 questionnaires were returned. The mean age of responder was 43 years and they had been qualified as a GP for a mean of 14 years (SD 9.03). Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. [Figure 1][1] illustrates the combinations of the main symptoms that GPs use to identify GCA with headache being the predominant feature (n=1071 (86%)). Other commonly reported features were visual disturbances (n=671 (53.9%)), jaw symptoms (n=420 (33.7%)) and temporal artery/scalp tenderness (n=468 (37.6%)). 21.86% (n=273) indicated that they only use headache as a symptom for identifying GCA. ![Figure 1.][2] Figure 1. Venn diagram of symptoms used to identify GCA. Conclusions General practitioners in the UK rely overly on headache when diagnosing GCA. Educating clinicians about other presenting symptoms and atypical presentations is essential to optimise diagnosis and reduce the potential for visual loss for this patient group and to reduce potentially serious long term complications. References 1. Barraclough K et al. Br J Gen Pract. 2012 Jun;62(599):329-3 2. Ezeonyeji A et al. Clin Rheumatol. 2011;30(2):259-262 Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4634 [1]: #F1 [2]: pending:yes

Background Giant cell arteritis (GCA) although the commonest large vessel vasculitis, is relatively uncommon in primary care. However, given the potentially serious complications of GCA including visual loss, general practitioners (GPs) need to recognise suspected GCA early and instigate appropriate management. UK BSR guidelines advocate early referral for specialist review and the initiation of treatment with high dose corticosteroids to minimise the likelihood of visual loss [1] Objectives The aim of this study was to investigate steroid management and referral patterns for GCA amongst UK GPs. Methods A postal questionnaire survey of 5000 randomly selected UK GPs was undertaken. Questions included experience of managing patients with GCA, initial steroid doses used and the referral pathways of suspected GCA. Results 1249 GPs responded (corrected response rate of 25.1%). Responders had a mean age of 44 years (SD 9.2) and had been qualified as a GP for a mean of 14 (SD 9.03) years. Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. The most common initiating dose of prednisolone was 60mg, although this varied widely (figure 1). Once GPs had suspected the diagnosis, 478 respondents (38.3%) indicated that they refer to rheumatology, 366 (29.3%) would refer to ophthalmology, 144 (11.5%) would refer to general medicine and 35 (2.8%) would refer to accident and emergency. Table 1 illustrates the action taken by respondents when GCA is suspected. Conclusions These results show that there appears to be wide variation amongst responders in how suspected GCA is managed in general practice. This is likely to be due to variation in the availability of relevant services. However, it may also reflect GPs training and previous experience. Referral pathways that allow urgent specialist review for diagnostic confirmation are essential to avoid the serious complications of GCA, but also inappropriate over treatment of patients who do not have the disorder. References Dasgupta B et al. Rheumatology (Oxford). 2010 Aug;49(8):1594-7. Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4756

Background The initial diagnosis of polymyalgia rheumatica (PMR) is often made in primary care. Given the non-specific nature of PMR symptoms, diagnosis can be challenging especially as many disorders can mimic the symptoms of PMR. Although guidelines are available1, studies suggest guidelines are rarely followed2 and that diagnostic accuracy is poor3. However, previous studies have relied upon data from retrospective case review or data from referral letters. Objectives The aim of this study was to describe how general practitioners (GPs) in the UK, report that they diagnose PMR based on symptoms, investigations and exclusion of other disorders. Methods 5000 randomly selected GPs in the UK were mailed a questionnaire on PMR. As part of the survey GPs were asked, in their routine practice, which clinical features were most important in diagnosing PMR and, what investigations they performed. They were also asked, what they would do if the inflammatory markers were normal and which disorders they would routinely try to exclude before making a formal diagnosis of PMR. Results 1249 (25.1%) GPs responded. Responders were generally from practices with larger list sizes and more GP principals than non-responders. GPs rated bilateral shoulder pain, raised inflammatory markers and response to corticosteroids as the most important clinical features for diagnosing PMR. Most respondents performed full blood count and ESR or CRP. Other recommended blood tests were performed less frequently (figure 1 ). 25% (n=315) of GPs reported that they would exclude PMR in patients with normal inflammatory markers, whilst 31% (n=392) would refer their patients to secondary care for specialist review. 80% (n=1001) of GPs sought to exclude giant cell arteritis (GCA). 61% (n=759) routinely excluded other rheumatological disorders, but just 55% (n=682) considered excluding relevant malignancies. Image/graph Conclusions This large GP survey suggests that despite using recommended clinical features to diagnose PMR and seeking to exclude GCA, many GPs do not routinely exclude other diagnoses as a cause of symptoms. This has significant implications for diagnostic accuracy which could result in prolonged, inappropriate treatment with corticosteroids or a missed opportunity for timely more appropriate intervention in disorders such as malignancy or rheumatoid arthritis. Further work is needed to investigate the accuracy of the diagnosis of PMR in primary care. References Rheumatology, 49(1), pp. 186-90. Family Practice, 25(5), pp. 328-333. Clinical rheumatology, 19(4), pp. 278-280. Disclosure of Interest None Declared

Norman and colleagues raise an important issue—sample size calculations are at best an educated guess.1 While their suggestion might be helpful when an idea of sample size can be gleaned, in a recent study we had very little information at all. The study was a primary care inception cohort of a rare and little researched condition. Initially, we …

It is potentially dangerous to suggest that normal inflammatory markers can be used to rule out illnesses such as giant cell arteritis and polymyalgia rheumatica.1 Although patients with polymyalgia rheumatica will …

BackgroundIn the UK, general practitioners (GPs) are usually the first medical contact for patients with suspected giant cell arteritis (GCA). While rare, it is critical not to miss, as delayed treatment can lead to significant complications including permanent visual loss. To date, little is known about the approach and challenges to diagnosis and management of GCA by GPs.ObjectiveTo investigate the diagnosis and management of patients with suspected GCA in UK general practice.Design and participantsA multimethods approach was taken, comprising a postal survey of 5000 randomly selected UK GPs and semistructured telephone interviews of 24 GPs from across the UK.SettingUK general practice.Results1249 questionnaires were returned. 879 responders (70%) indicated that they had diagnosed and managed a patient with GCA. A variety of clinical features were used to identify GCA. 21.9% suggested that they would exclude GCA as a diagnosis if headache was absent and around one-third do not routinely initiate glucocorticoid treatment prior to referral. Significant regional variations in referral pathways were reported. Thematic analysis of interview transcripts highlighted fears relating to a missed diagnosis of GCA and the non-specific nature of early GCA presentation. Accessing specialist care was highlighted as challenging by many GPs and that a national standard fast-track pathway is lacking to support this patient group. Additionally there were significant concerns regarding potential adverse effects relating to long-term treatment with glucocorticoids.ConclusionGPs appear to over-rely on headache to identify GCA and marked geographical differences in management, with conflicting referral pathways and difficulties in accessing appropriate services exist in the UK. A national standard for fast-tracking patients with suspected GCA to relevant specialists would be beneficial to improve care and outcomes for patients with GCA.