From the Guidelines
Polymyalgia rheumatica (PMR) should be treated with low-dose oral prednisone, usually 12.5-25mg daily, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1.
Treatment Approach
The treatment approach for PMR involves several key steps, including:
- Assessing comorbidities and possible risk factors for relapse/prolonged therapy
- Considering specialist referral, particularly in cases of atypical presentation or high risk of therapy-related side effects
- Documenting a minimal clinical and laboratory dataset
- Starting oral prednisone at a dose of 12.5-25mg/day and gradually tapering the dose by 1-2.5mg every 2-4 weeks
- Monitoring symptoms, inflammatory markers, and potential steroid side effects regularly
Management Principles
The management of PMR should be based on the following overarching principles:
- Adoption of a safe and specific approach to ascertain the PMR case definition
- Assessment of comorbidities and risk factors for steroid-related side effects
- Consideration of specialist referral and individualized treatment plans
- Regular monitoring and documentation of clinical and laboratory data
- Patient education and access to advice from healthcare professionals
Key Recommendations
The 2015 EULAR/ACR recommendations for the management of PMR emphasize the importance of:
- Using a shared decision-making approach between the patient and treating physician
- Considering the patient's perspective and preferences in the individualized choice of initial GC dose and subsequent tapering of GCs
- Providing patients with access to education and advice on individually tailored exercise programs
- Ensuring rapid and direct access to advice from healthcare professionals in case of changes in the patient's condition.
From the Research
Overview of Polymyalgia Rheumatica
- Polymyalgia rheumatica (PMR) is a systemic inflammatory disease of unknown cause that affects older individuals 2.
- Clinical symptoms respond promptly to corticosteroids, but treatment is often required for several years, frequently resulting in adverse drug effects 2.
Treatment of Polymyalgia Rheumatica
- The standard treatment for PMR is based on low-dose glucocorticoids, with prednisone being the most commonly used steroid 3, 4.
- Starting prednisone doses of 10-20 mg/day yield clinical improvement in the majority of patients with PMR, generally achieved within 7 days of the onset of this therapy 3, 4.
- Methotrexate is the most commonly used corticosteroid-sparing agent, and is associated with shorter prednisone treatment and steroid sparing 3, 5, 4.
- Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 3.
Disease Management and Relapses
- Relapses of PMR are not uncommon when the dose of prednisone is equal to or below 5 mg/day 4.
- Conditions different from isolated PMR should be considered in atypical cases or when a good response to 20 mg/day of prednisone is not achieved 4.
- Methotrexate is often used for disease management, especially for relapses of the disease, although it may yield a modest effect 6.
New Therapies and Future Directions
- Randomized controlled trials do not support the use of antitumor necrosis factor agents in PMR 6.
- Several case series and retrospective studies have highlighted the efficacy of the anti-interleukin-6 receptor antibody tocilizumab in PMR, although controlled trials are needed to fully establish its efficacy 6.
- The potential beneficial effect of the Janus-kinase inhibitors remains to be determined 6.