From the Guidelines
Polymyalgia rheumatica is an inflammatory disorder that causes muscle pain and stiffness, primarily affecting people over age 50, and is typically treated with low-dose corticosteroids, such as prednisone, with an initial dose of 12.5-25mg daily, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1. The condition usually causes aching and stiffness in the shoulders, neck, upper arms, hips, and thighs, with symptoms typically worse in the morning or after periods of inactivity. Some key points to consider in the management of polymyalgia rheumatica include:
- Assessing comorbidities, other relevant medications, and possible risk factors for steroid-related side effects and relapse/prolonged therapy 1
- Using a minimal clinical and laboratory dataset to document patient information before prescribing therapy 1
- Considering specialist referral for patients with atypical presentation or high risk of therapy-related side effects and/or relapse/prolonged therapy 1
- Tapering the oral dose of prednisone gradually to a dose of 10 mg/day within 4-8 weeks, and then further tapering by 1 mg/4 weeks until discontinuation, once remission is achieved 1
- Monitoring patients regularly, every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as indicated in case of relapse or as prednisone is tapered off 1 The exact cause of polymyalgia rheumatica remains unknown, but it is believed to involve genetic and environmental factors triggering an autoimmune response. Regular monitoring is essential during treatment to manage potential side effects of corticosteroids, including osteoporosis, diabetes, and hypertension. It is also important to note that polymyalgia rheumatica is sometimes associated with giant cell arteritis, a more serious condition that can cause headaches, jaw pain, and vision problems requiring immediate medical attention.
From the Research
Definition and Characteristics of Polymyalgia Rheumatica
- Polymyalgia rheumatica (PMR) is a systemic inflammatory disease of unknown cause that affects older individuals 2.
- It is characterized by pain and morning stiffness in the shoulder and pelvic girdle with synovitis of the proximal joints and extra-articular synovial structures 3.
- Classic symptoms include pain and long-term morning stiffness of the neck, shoulders, hips, upper arms, and thighs 4.
Diagnosis and Treatment
- The diagnosis of PMR is based on clinical assessment, as no specific laboratory test exists for the disorder 4.
- Provisional classification criteria were published in April 2012 by a collaborative initiative of the European League Against Rheumatism and the American College of Rheumatology 4.
- The standard treatment is low-dose glucocorticoids, which provide symptomatic relief for most patients 4.
- Low dose oral steroids (prednisolone 10-15 mg daily) are currently advocated for the treatment of uncomplicated PMR 5.
- Intramuscular methylprednisolone has been shown to have a similar remission rate to oral steroids and a better side effect profile with respect to fracture rate and weight gain 5.
Disease Variations and Treatment Requirements
- PMR is a heterogeneous disease with variations in the treatment duration and dose of corticosteroids required for suppression of symptoms 2.
- Pretreatment erythrocyte sedimentation rate and nonresponsiveness of interleukin 6 to steroid therapy are helpful in dividing patients into subsets with different treatment requirements 2.
- Corticosteroid-sparing therapy with adjunctive methotrexate may benefit select patients 6.