From the Guidelines
The most appropriate pharmacotherapy for this patient is prednisone (option E). This 72-year-old woman presents with symptoms highly suggestive of polymyalgia rheumatica (PMR), including bilateral shoulder and hip girdle pain that worsens with movement, general malaise, and a markedly elevated erythrocyte sedimentation rate (112 mm/h) 1. The normal creatine kinase and electromyography findings help rule out inflammatory myopathies. PMR is an inflammatory condition that typically affects older adults and responds dramatically to glucocorticoid therapy.
Key Considerations
- Prednisone at an initial dose of 12.5-25 mg daily is recommended as the first-line treatment for PMR, with the goal of providing rapid symptom relief within days 1.
- The dose can then be gradually tapered over months based on clinical response and normalization of inflammatory markers, with a suggested tapering schedule of 1 mg every 4 weeks once remission is achieved 1.
- Patients typically require treatment for 1-2 years, with careful monitoring for steroid-related side effects.
- The other medications listed would not effectively address the underlying inflammatory process of PMR - azathioprine is used for autoimmune conditions but not first-line for PMR, colchicine is for gout, gabapentin for neuropathic pain, and ibuprofen would provide inadequate anti-inflammatory effect for this condition.
Treatment Approach
- The panel strongly recommends using glucocorticoids (GCs) instead of NSAIDs in patients with PMR, with the exception of possible short-term use of NSAIDs and/or analgesics in PMR patients with pain related to other conditions 1.
- The panel conditionally recommends considering early introduction of methotrexate (MTX) in addition to GCs, particularly in patients at a high risk for relapse and/or prolonged therapy as well as in cases with risk factors, comorbidities and/or concomitant medications where GC-related adverse events are more likely to occur 1.
- Methotrexate has been used at oral doses of 7.5–10 mg/week in clinical trials 1.
- The panel strongly recommends against the use of TNFα blocking agents for treatment of PMR 1.
From the Research
Diagnosis and Treatment
The patient's symptoms, such as general malaise, aching pain in the shoulders and hips, and elevated erythrocyte sedimentation rate, are consistent with polymyalgia rheumatica (PMR) 2, 3.
Pharmacotherapy Options
The following pharmacotherapy options are considered for PMR:
- Azathioprine: Not typically used as a first-line treatment for PMR
- Colchicine: Not commonly used for PMR
- Gabapentin: Not typically used for PMR
- Ibuprofen: May be used for mild cases, but not as effective as steroids for PMR
- Prednisone: The standard treatment for PMR, with a typical starting dose of 12.5-25 mg/day 3
Evidence for Prednisone
Studies have shown that prednisone is effective in inducing remission and preventing relapse in PMR patients 2, 3, 4. Methotrexate may be considered as a glucocorticoid-sparing agent in patients who relapse or experience adverse effects from prednisone 2, 5, 6, 4.
Conclusion Not Provided as per Request
Key points to consider: