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Timed Release Tablet Prednisone in Polymyalgia Rheumatica

This study has been completed.
Information provided by (Responsible Party):
University Hospitals Bristol NHS Foundation Trust Identifier:
First received: February 2, 2009
Last updated: September 4, 2015
Last verified: September 2015

February 2, 2009
September 4, 2015
October 2009
November 2010   (Final data collection date for primary outcome measure)
Peak serum IL-6 concentration [ Time Frame: 24 hours ]
As measured from (approximately) hourly blood sampling over 24 hours
To show that the circadian variations in IL−6 and other cytokines in PMR can be altered by TRT Prednisone, and if this coincides with an improvement in symptoms. We will show that timing of treatment is important in the treatment of PMR. [ Time Frame: 18-24 months ]
Complete list of historical versions of study NCT00836810 on Archive Site
  • Morning stiffness (minutes) [ Time Frame: 24 hours ]
    How long was your morning stiffness today?
  • Pain (severity) [ Time Frame: 24 hours ]
    100mm visual analogue scale. Question: How much pain have you had in the last 24 hours? Anchors: No pain; Severe pain.
  • Patient's opinion of condition [ Time Frame: Current ]
    100mm visual analogue sacale. Question: Considering all the ways your pain and/or stiffness affect(s) you, please mark on the line how well you are doing. Anchors: Very well; Very badly.
  • Clinician's opinion of disease activity. [ Time Frame: Current ]
    100mm visual analogue scale. Question: Clinician's opinion of disease activity. Anchors: None; Severe
  • PMR Disease Activity Score [ Time Frame: Current ]
    Numerical value of: CRP (mg/dl) + Patient's opinion of condition (mm) + Clinician's opinion of condition (mm) + morning stiffness (min x 0.1) + Elevation of upper limb (0-3 scale).
  • Serum cortisol [ Time Frame: 24 hours ]
    Measurement of circadian change in serum cortisol in (approximately) hourly blood samples
  • Disability (HAQ) [ Time Frame: Past week ]
    Health Assessment Questionnaire Disability Index
  • Fatigue (BRAF - MDQ) [ Time Frame: One week ]
    Bristol Rheumatoid Arthritis Fatigue Multi Dimensional Questionnaire
We will advance our understanding of the pathogenesis (causes and mechanism) of PMR. [ Time Frame: 18-24 months ]
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Timed Release Tablet Prednisone in Polymyalgia Rheumatica
Circadian Variation in Cytokines and the Effect of Timed Release Tablet Prednisone in Polymyalgia Rheumatica

Polymyalgia Rheumatica (PMR) is a disease that usually affects older people. Patients complain of stiffness and pain around the shoulders and hips. The stiffness is more severe in the morning. The joints are not affected by this disease.

Research in Rheumatoid Arthritis (RA), which is also much worse in the mornings, has shown that IL−6 (a chemical messenger) peaks in the morning with very low levels in the evening. This may explain why stiffness is most severe in the morning. The investigators have recently shown that timed release tablet (TRT) prednisone reduced morning IL−6 levels close to normal in RA patients.

In PMR, IL−6 levels are high. Given that both RA and PMR have the same variation of symptoms (worse in the morning); it's likely that PMR patients have the same variation in IL−6 levels. In a pilot study of 4 patients conducted within our department, IL−6 levels did, indeed, show a pattern similar to that found in RA patients, but the number of patients is small and the results need to be confirmed.

PMR is treated with moderate doses of glucocorticoid for about 2 years. While generally abolishing symptoms, these doses are very likely to cause adverse effects such as high blood pressure, weight gain and diabetes. These side effects are much less frequent when lower doses are used but these are not sufficient to control PMR using traditional dosing regimes.

Therefore, the investigators wish to investigate whether TRT prednisone in PMR will reduce IL−6 and morning symptoms similar to those in RA. The investigators think that it will do so, and will achieve symptomatic relief at a lower dose. If this is the case, then treating patients with lower doses may mean reduced risk of glucocorticoid induced side effects in the future.

Patients will be recruited through the outpatient clinics at the University Hospitals Bristol, NHS Foundation Trust, Rheumatology Centre. Each patient will give fully informed consent after being given details of the study and a patient information sheet. The research doctor will take the consent 2−5 days after this information has been provided and with the presence of a witness. The study will consist of the collection and analysis of sequential blood samples over a 24 hour period on 2 occasions 2 weeks apart, taking TRT prednisone 7 mg / standard release prednisolone 7 mg for the intervening period. The investigators will aim to recruit 12 patients in each arm. A single blood sample will be taken when the patient comes for a routine review 2 weeks later.

The volunteers will stay overnight in the Rheumatology Centre; 24-hour Research Facility on two occasions (Night A and Night B) 12-16 days apart. This slight flexibility will allow some leeway in arranging residency nights. In general the investigators will aim for 14 days. After Night A, each volunteer will be randomized (in pre-prepared sealed envelopes) to take one tablet morning or evening. Half the patients will take active standard release prednisolone in the morning. The other half will receive active TRT Prednisone 7mg to be taken each evening at 22:00 until the day after Night B. All study medication will then be discontinued and standard therapy (prednisolone 15mg each morning) commenced. Patients will be reviewed after 2 weeks to ensure expected clinical response and to measure IL-6 and other cytokines in the blood sample that is also needed to check the acute phase response.

On Night A and Night B, volunteers will attend the Rheumatology Centre at 15:00.

First, standard assessment tools will be used by the research doctor to assess the state of the patient's condition.

These assessments will be:

  • Morning stiffness (minutes)
  • Pain (visual analogue scale)
  • Patient's opinion of condition
  • Clinician's opinion of condition
  • Health Assessment Questionnaire
  • BRAF-MDQ fatigue scale and the Hospital Anxiety and Depression Scale.

An intravenous (IV) cannula will be inserted into the elbow area. At least one hour after the IV cannula is placed, but usually at 16:30, a blood sample (2ml) will be taken through the IV cannula and the cannula flushed. At 22:30 the main lights will be switched off and the volunteer encouraged to sleep. In total, 20 samples will be taken from the cannula over 24 hours.

The investigators will calculate mean and standard deviation (or non-parametric analysis if the data are not normally distributed) for blood cytokines for each time point. These mean and standard deviations will be compared for pre- and post-TRT prednisone samples.

Phase 2
Phase 3
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Polymyalgia Rheumatica
  • Drug: Timed Release Tablet Prednisone
    Dose: 7mg, taken at 10pm every night for 2 weeks in the form of oral tablets.
    Other Name: Lodotra
  • Drug: Prednisolone
    Dose: 7mg, taken in the morning for 2 weeks in the form of oral tablets.
  • Experimental: Timed Release Tablet Prednisone
    12 patients will be taking the intervention night time timed release tablet (TRT) prednisone at a dose of 7mg a day over 2 weeks.
    Intervention: Drug: Timed Release Tablet Prednisone
  • Active Comparator: Standard Prednisolone
    12 patients will be taking morning Prednisolone at a dose of 7mg over 2 weeks.
    Intervention: Drug: Prednisolone
Not Provided

*   Includes publications given by the data provider as well as publications identified by Identifier (NCT Number) in Medline.
March 2011
November 2010   (Final data collection date for primary outcome measure)

Inclusion Criteria:

  • Diagnosis of PMR by standard criteria. The Bird criteria will be used. 3 or more features are required to make the diagnosis.

    • Bilateral shoulder pain/stiffness
    • Duration of symptoms <2/52
    • Initial ESR >40 mm/h
    • Stiffness >1 h
    • Age >65 years
    • Depression and/or weight loss
    • Bilateral upper arm tenderness
  • Are over 50 but less than 85 years old.
  • No or stable NSAID or analgesic therapy for at least 7 days.
  • Currently active disease defined by a CRP at least 10mg/L, ESR at least 29mm in one hour or PV >1.72

Exclusion Criteria:

  • Currently on oral glucocorticoid treatment or taken within 2 months
  • Parenteral glucocorticoid treatment with the last 2 months
  • Pregnancy and lactation
  • Inflammatory diseases such as inflammatory bowel disease, colitis, asthma
  • Co-existent giant cell arteritis
  • Other auto-immune diseases
  • Cancer
  • Infections, treatment with antibiotics within the past 6 weeks
  • Significant renal disease (creatinine >150 μmol/L)
  • Significant hepatic impairment
  • Participation in a clinical trial within the past 30 days
  • Working shift employee
  • Jet lag
Sexes Eligible for Study: All
50 Years to 85 Years   (Adult, Senior)
Contact information is only displayed when the study is recruiting subjects
United Kingdom
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University Hospitals Bristol NHS Foundation Trust
University Hospitals Bristol NHS Foundation Trust
Not Provided
Principal Investigator: John R Kirwan, MBBS,MD,FRCP University Hospitals Bristol NHS Foundation Trust
University Hospitals Bristol NHS Foundation Trust
September 2015

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP