What is polymyalgia rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) should be treated with low-dose corticosteroids, specifically prednisone starting at 12.5-25 mg daily, as this approach has been shown to be effective in managing the condition while minimizing the risk of adverse events 1.

Key Considerations

• The treatment of PMR should be individualized, taking into account the patient's comorbidities, risk factors for steroid-related side effects, and preferences 1.
• Patients should be monitored regularly, with assessments of symptoms, inflammatory markers (ESR and CRP), blood glucose, and bone density, to ensure that the treatment is effective and to minimize the risk of adverse events 1.
• Steroid-sparing agents like methotrexate may be considered for patients requiring prolonged therapy, as they have been shown to be effective in reducing the cumulative dose of glucocorticoids and improving remission rates 1.

Treatment Approach

• The initial dose of prednisone should be 12.5-25 mg daily, with the goal of achieving a rapid improvement in symptoms within 24-48 hours 1.
• The dose should be maintained for 2-4 weeks until symptoms resolve, then gradually tapered over months to years to the lowest effective dose 1.
• Patients should take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements to prevent bone loss, and may need a proton pump inhibitor for gastric protection 1.

Prognostic Factors

• Female sex, high erythrocyte sedimentation rate (ESR), and peripheral arthritis have been identified as potential risk factors for a worse prognosis in PMR, including a higher relapse risk and longer duration of treatment 1.
• However, the evidence for these prognostic factors is not consistent, and further research is needed to fully understand their role in PMR 1.

From the Research

Definition and Symptoms of Polymyalgia Rheumatica

• Polymyalgia rheumatica (PMR) is the most common autoimmune inflammatory disease in older persons, with an average age of onset of 73 years 2.
• Typical symptoms include acute or subacute bilateral shoulder pain with severe stiffness and often neck and bilateral hip pain 2.

Diagnosis of Polymyalgia Rheumatica

• There are no specific laboratory tests for PMR, but C-reactive protein and erythrocyte sedimentation rates are elevated in over 90% of patients 2.
• The diagnosis may be aided by imaging, especially ultrasonography and magnetic resonance imaging (MRI) 2.
• Elderly onset rheumatoid arthritis is frequently misdiagnosed as PMR, and other diseases may also mimic PMR 2.

Treatment of Polymyalgia Rheumatica

• Treatment currently consists of glucocorticoids at an initial dose of 12.5-25 mg prednisone equivalent daily 2.
• Treatment duration is typically 2-3 years but may be longer 2.
• Under certain conditions, low-dose methotrexate can be used as adjuvant therapy 2, 3, 4, 5.
• Starting prednisone doses higher than 10 mg/d were associated with fewer relapses and shorter therapy than were lower doses 4.
• Slow prednisone dose tapering (<1 mg/mo) was associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 4.

Use of Methotrexate in Polymyalgia Rheumatica

• Methotrexate may exert glucocorticoid-sparing properties 4.
• Initial addition of oral or intramuscular methotrexate provided efficacy at doses of 10 mg/wk or higher 4.
• However, some studies found no steroid-sparing effect of methotrexate in a dosage of 7.5 mg/week 5.
• Methotrexate can be used to treat corticosteroid-resistant PMR and giant cell arteritis 3.