What is the treatment for suspected Polymyalgia Rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) is best treated with low-dose oral corticosteroids, typically starting with prednisone 12.5-25 mg daily, as recommended by the European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The initial dose should be individualized based on the patient's risk of relapse and side effects, with a higher dose considered for those at high risk of relapse and a lower dose for those with comorbidities or risk factors for glucocorticoid-related side effects. Some key points to consider in the treatment of PMR include:

• The use of glucocorticoids (GCs) as the primary treatment, with the goal of achieving remission and minimizing side effects 1
• The importance of individualizing the GC dose and tapering schedule based on the patient's response and risk factors 1
• The potential benefits of adding methotrexate as a steroid-sparing agent for patients who cannot tolerate or respond inadequately to GCs 1
• The need for regular monitoring of symptoms, inflammatory markers, and steroid side effects to guide treatment decisions 1
• The importance of evaluating patients for giant cell arteritis, particularly if they develop headaches, jaw claudication, or visual disturbances, as this related condition requires more urgent and aggressive treatment 1

In terms of specific treatment regimens, the European League Against Rheumatism/American College of Rheumatology collaborative initiative recommends:

• Initial GC doses of 12.5-25 mg prednisone equivalent daily, with a higher dose considered for those at high risk of relapse and a lower dose for those with comorbidities or risk factors for GC-related side effects 1
• Tapering the GC dose to 10 mg/day prednisone equivalent within 4-8 weeks, followed by slower reductions of 1 mg every 4 weeks until discontinuation 1
• Considering the addition of methotrexate for patients who cannot tolerate or respond inadequately to GCs, with a typical dose of 7.5-10 mg/week 1

Overall, the treatment of PMR should be individualized based on the patient's specific needs and risk factors, with the goal of achieving remission and minimizing side effects.

From the FDA Drug Label

INDICATIONS AND USAGE PredniSONE Tablets are indicated in the following conditions: ... 2 Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: ... Polymyositis

The treatment of suspected polymyositis (also referred to as polymyalgia) may involve the use of prednisone.

• The prednisone dosage will depend on the severity of the disease and the patient's response to treatment.
• It is essential to individualize and tailor the therapy to each patient.
• The benefits and risks of corticosteroid therapy should be carefully weighed for each patient. 2

From the Research

Treatment of Suspected Polymyalgia

• The standard treatment for polymyalgia rheumatica is steroids, with an initial dose of prednisone of 10-20 mg/day yielding clinical improvement in the majority of patients 3.
• Methotrexate is the conventional disease-modifying antirheumatic drug most commonly used for disease management, especially for relapses of the disease 4.
• The efficacy of methotrexate in polymyalgia rheumatica has been demonstrated in several studies, with results showing that methotrexate plus prednisone is associated with shorter prednisone treatment and steroid sparing 5, 6.

Methotrexate Dosage

• Earlier trials of low to medium quality only studied methotrexate dosages of 7.5-10 mg/week with no to modest effect 7.
• Higher doses of methotrexate (25 mg/week) may be more effective, as recommended for other inflammatory rheumatic diseases 7.
• A double-blind, randomized, placebo-controlled superiority trial (PMR MODE) is currently studying the efficacy of methotrexate 25 mg/week versus placebo in recently diagnosed polymyalgia rheumatica patients 7.

Treatment Goals

• The main goals of treatment are to induce remission and prevent relapse 4.
• Conditions different from isolated polymyalgia rheumatica should be considered in atypical cases or when a good response to 20 mg/day of prednisone is not achieved 3.
• Relapses of polymyalgia rheumatica are not uncommon when the dose of prednisone is equal to or below 5 mg/day 3.

Other Treatment Options

• Antitumor necrosis factor agents are not supported by randomized controlled trials for use in polymyalgia rheumatica 4.
• The anti-interleukin-6 receptor antibody tocilizumab has shown efficacy in several case series and retrospective studies, but controlled trials are needed to fully establish its efficacy 4.
• The potential beneficial effect of the Janus-kinase inhibitors remains to be determined 4.