Performance of the Polymyalgia Rheumatica Activity Score for Diagnosing Disease Flares AYMERIC BINARD, 1 MICHEL DE BANDT, 2 JEAN-MARIE BERTHELOT, 3 ALAIN SARAUX, 1 FOR THE INFLAMMATORY JOINT DISEASE WORKING GROUP OF THE FRENCH SOCIETY FOR RHEUMATOLOGY Objective. To evaluate the effectiveness of the polymyalgia rheumatica activity score (PMR-AS) in diagnosing disease flares. Methods. Rheumatologists prospectively included 89 patients with PMR (mean  SD age 74.6  6.2 years, mean  SD disease duration 1.6  2.2 years). At each visit, the rheumatologist assessed disease activity using a visual analog scale (VAS) and recorded whether a disease flare was diagnosed and/or the glucocorticoid dose changed. Overall, 137 visits including 49 pairs (allowing intraindividual comparisons) were available; a disease flare was diagnosed at 32 visits. We evaluated statistical associations linking flare diagnosis to the PMR-AS, each of its components (VAS, VAS for pain, C-reactive protein, morning stiffness, and elevation of upper limbs), and changes in these parameters between 2 visits. Results. Associations with disease flare diagnosis were strongest for PMR-AS scores >9.35 (agreement 92%, 95% confidence interval [95% CI] 85.8 –95.7%,   0.78; sensitivity 96.6%, 95% CI 80.4 –99.8; specificity 90.7%, 95% CI 83.2–95.2) and for PMR-AS scores >6.6 (agreement 98%, 95% CI 88.0 –99.9%,   0.95; sensitivity 100%, 95% CI 74.7–100; specificity 97.1%, 95% CI 82.9 –99.8). Other parameters showed weaker diagnostic performance. Conclusion. This study supplies new evidence that the PMR-AS is useful for monitoring PMR activity in everyday practice and for managing glucocorticoid tapering. PMR activity changes seem even more relevant than absolute values. INTRODUCTION Polymyalgia rheumatica (PMR) is a clinical syndrome of the elderly characterized by pain and morning stiffness in the neck and limb girdles, usually with elevations in eryth- rocyte sedimentation rate (ESR) and serum C-reactive pro- tein (CRP) level. Systemic glucocorticoid therapy is the treatment of choice. Low dosages (10 –20 mg/day of pred- nisone) are sufficient to correct the clinical symptoms and laboratory evidence of inflammation within a few days. The glucocorticoid dose is then tapered according to dis- ease activity. Monitoring of disease activity and detection of flares usually relies on a combination of clinical symp- toms with ESR and/or CRP (1). However, the definition of PMR flare is not universally agreed on, and no criteria for PMR relapse have been published. The risk of disease flare is difficult to assess, which may lead physicians to delay glucocorticoid tapering. Delayed tapering unnecessarily prolongs exposure to the adverse effects of glucocorti- coids, an obvious concern in elderly individuals. Better tailoring of the glucocorticoid dose to disease activity would substantially improve the treatment of patients with PMR. To achieve this goal, an effective tool for eval- uating disease activity is needed. The European Collaborating Polymyalgia Rheumatica Group developed European League Against Rheumatism (EULAR) response criteria for PMR in 2003 (2). Leeb and Bird (3) used these criteria to create a PMR activity score (PMR-AS) based on 5 variables: morning stiffness (in min- utes), ability to elevate the upper limbs (on a scale from 0 to 3), physician’s global assessment on a 10-point visual analog scale (VASph), pain severity on a 10-point VAS (VASp), and CRP level (in mg/dl). PMR-AS values 7 indicated low disease activity, values between 7 and 17 indicated moderate disease activity, and values 17 indi- cated high disease activity. However, a PMR-AS threshold highly predictive of a need for an increased glucocorticoid dose remained to be determined. In a previous study (4), we used clinical vignettes to evaluate the effectiveness of the PMR-AS in diagnosing flares that required glucocorticoid dose escalation. PMR-AS values 7 defined a flare with 98.1% sensitivity 1 Aymeric Binard, MD, Alain Saraux, MD, PhD: Brest Teaching Hospital, Brest Cedex, France; 2 Michel De Bandt, MD, PhD: Robert Ballanger Hospital, Aulnay sous Bois, France; 3 Jean-Marie Berthelot, MD: Nantes Teaching Hospi- tal, Nantes, France. Address correspondence to Alain Saraux, MD, PhD, Rheumatology Unit, Ho ˆ pital de la Cavale Blanche, BP 824, F 29609 Brest Cedex, France. E-mail: Alain.Saraux@chu- brest.fr. Submitted for publication May 31, 2007; accepted in re- vised form September 10, 2007. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 59, No. 2, February 15, 2008, pp 263–269 DOI 10.1002/art.23338 © 2008, American College of Rheumatology ORIGINAL ARTICLE 263