[S3 guidelines on treatment of polymyalgia rheumatica : Evidence-based guidelines of the German Society of Rheumatology (DGRh), the Austrian Society of Rheumatology and Rehabilitation (ÖGR) and the Swiss Society of Rheumatology (SGT) and participating medical scientific specialist societies and other organizations]. / S3-Leitlinie zur Behandlung der Polymyalgia rheumatica : Evidenzbasierte Leitlinie der Deutschen Gesellschaft für Rheumatologie (DGRh), der Österreichischen Gesellschaft für Rheumatologie und Rehabilitation (ÖGR) und der Schweizerischen Gesellschaft für Rheumatologie (SGR) und der beteiligten medizinisch-wissenschaftlichen Fachgesellschaften und weiterer Organisationen.

Polymyalgia rheumatica (PMR) occurs almost exclusively in persons aged 50 years or older and it is the second most common inflammatory rheumatic disease in older people after rheumatoid arthritis. Since there are no specific tests for PMR, the exclusion of clinically similar differential diagnoses is essential to ascertain the diagnosis. These recommendations for the management of PMR assume an already established diagnosis of PMR. It is recommended to initiate treatment with glucocorticoids immediately after diagnosis and to provide appropriate patient information and education about the impact of the disease and its treatment. Methotrexate should be considered in patients at high risk for relapse and/or glucocorticoid-related adverse events. These guidelines have been elaborated because there is significant heterogeneity in the management of PMR in clinical practice in Germany (but also Europe and worldwide), despite the large number of patients with this disease. These guidelines are primarily based on the 2015 EULAR-ACR recommendations for the management of PMR, which were updated by the guideline committee and adapted to the German speaking countries.

[Multimorbidity in elderly rheumatic patients part 1]. / Multimorbidität bei älteren Rheumapatienten Teil 1.

An appropriate treatment of elderly rheumatic patients implements comprehensive diagnostics and exclusion diagnostics of e.g. coronary heart disease, osteoporosis, renal failure, diabetes mellitus type 2 and thyroid gland dysfunction. Furthermore, the complex disease situation might require the integration of other faculties or might be a reason for inpatient treatment. The complexity in the treatment of multimorbid elderly patients suffering from rheumatism not only rises with increasing age but also constitutes a considerable challenge due to existing incapacities and preceding as well as currently performed immunosuppressive therapies. The necessary treatment framework is outlined from the perspective of rheumatologists and geriatricians. Typical geriatric symptoms, such as malnutrition, immobility and frailty might be enhanced if multimorbidity is simultaneously present.

[Multimorbidity in elderly rheumatic patients part 2]. / Multimorbidität bei älteren Rheumapatienten Teil 2.

While diseases, such as cardiovascular diseases and osteoporosis in the elderly are categorized as comorbidities of rheumatoid arthritis, elderly rheumatic patients are often additionally affected by thyroid dysfunctions and diabetes mellitus type 2, so that the risk of multimorbidity (coexistence of at least two chronic and/or acute diseases) will increase significantly in elderly patients already suffering from systemic rheumatic diseases. Restricted cognition, adherence or compliance may additionally complicate the treatment of elderly rheumatic patients. Furthermore, the pharmacokinetics of the elderly is another challenging task. Referring to selected aspects of geriatric pharmacotherapy, the use of certain substance classes is described in this context.

[Pharmacological treatment of osteoarthritis in the elderly]. / Medikamentöse Arthrosetherapie im Alter.

Osteoarthritis (OA) is the most common cause of functional disability in the elderly. Pain and loss of motion induce a vicious circle, leading to instability, frailty and ultimately invalidity. Currently, there is no treatment to reverse or slow the disease progression to a clinically meaningful extent. Thus, the primary goal of OA treatment in the elderly is pain relief and preservation of joint function. For this, pharmacological, non-pharmacological and if necessary surgical treatment regimes must form an integrated concept. However, the real challenge is polymorbidity and other age-related or age-associated factors, which influence the course of disease and its therapy unfavorably. The changes in pharmacokinetics and -dynamics in the elderly can be compensated for the nonopioid and opioid-analgesics by the well known "start low, go slow" approach. More problematic are non-steroidal anti-inflammatory drugs (NSAIDs), which are most often used for symptomatic treatment of OA: Patients over 65 have an enhanced susceptibility to the gastrointestinal and renal side effects of NSAIDs; all NSAIDs, not only coxibs, increase the cardiovascular risk in patients with such a disease; number and severity of drug interactions is elevated due to age-associated polypharmacy. Thus, NSAIDs, including coxibs, should be used with great caution for treatment of OA in the elderly.

[Effectiveness of vitamin E in comparison with diclofenac sodium in treatment of patients with chronic polyarthritis]. / Wirksamkeit von Vitamin E im Vergleich zu Diclofenac-Natrium in der Behandlung von Patienten mit chronischer Polyarthritis.

In a randomized, double blind parallel group comparison the antiphlogistic and analgetic efficacy of high-dosed vitamin E (3 x 400 mg RRR-alpha-Tocopherolacetat/d) versus diclofenac-sodium has been investigated in hospitalized patients with established chronic rheumatoid arthritis. After 3 weeks of treatment the vitamin E group (n = 42) as well as the diclofenac group (n = 43) showed a significant improvement of all assessed clinical parameters. Duration of morning stiffness could be reduced under vitamin E treatment from 90 min to 68 min and under diclofenac treatment from 68 min to 30 min. The joint index according to Richie declined from 56 to 46 (vitamin E) and 49 to 34 (diclofenac). Grip strength increased in the vitamin E group as well as in the diclofenac group. In addition, the degree of pain, assessed by a 10 cm visual analogue scale, reduced significantly under vitamin E as well as under diclofenac. Regarding the therapeutical result both, physicians and patients, considered both drugs to be similarly effective. Especially regarding the risk profile of NSAR in long-term treatment of chronic rheumatoid arthritis intake of high-dosed vitamin E is a possible alternative in the treatment of inflammatory rheumatoid diseases.

[Reactive arthritis after cat bit: a rare manifestation of cat scratch disease--case report and overview]. / Reaktive Arthritis nach Katzenbiss: eine seltene Manifestation der Katzenkratzkrankheit--Kasuistik und Ubersicht.

Cat scratch disease (CSD) is a rarely recognized infectious disease in Germany. Only a few years ago the causative agent, Bartonella henselae, could be isolated. The typical clinical manifestations of CSD consist of skin changes at the inoculation site and a benign lymphadenopathy; other manifestations are rare. We report the case of a 47 year old woman, who developed a reactive spondylarthropathy with synovitis of finger joints, polyarthralgias of large- and medium-sized joints, and inflammatory spinal pain after a cat bite. The rheumatic manifestations resolved after 10 months by treatment with non-steroidal antirheumatic drugs. Only a few cases of rheumatic manifestations associated with CSD have been described in the literature. Because the prevalence of Bartonella henselae infection of cats is high in Europe, rheumatic manifestations might be more frequent. Diagnosis of CSD is now improved by the development of serological tests. We provide an overview of the clinical manifestations and the diagnostic criteria.