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 side effects. The treatment of PMR typically involves a gradual tapering of the corticosteroid dose over 1-2 years to prevent relapse while minimizing side effects 1. Patients usually experience dramatic improvement within 24-48 hours of starting treatment, which is so characteristic that it can help confirm the diagnosis.
Key Considerations in PMR Management
- The dose of prednisone should be individualized based on the patient's response to treatment and the presence of comorbidities, with a higher dose favored in patients with a high risk of relapse and a lower dose favored in patients with a high risk of side effects 1.
- Patients should take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements to prevent osteoporosis, and may need a bisphosphonate if on long-term steroids.
- Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential.
- Physical therapy and regular gentle exercise help maintain muscle strength and joint mobility.
- PMR is often associated with giant cell arteritis in about 15-30% of cases, which requires immediate attention if symptoms like headache, jaw pain, or visual disturbances develop, as higher steroid doses would be needed to prevent vision loss.
Treatment Approach
- The initial treatment approach should involve a shared decision between the patient and the treating physician, taking into account the patient's preferences and values 1.
- Patients should have access to education focusing on the impact of PMR and treatment, including comorbidities and disease predictors, and advice on individually tailored exercise programmes.
- Every patient treated for PMR should be monitored with regular follow-up visits, suggested 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 and discontinued 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, although the evidence is not consistent across all studies 1.
Therapeutic Interventions
- Methotrexate has been shown to be effective in reducing relapse rates and cumulative glucocorticoid doses in early PMR, although the evidence is limited to a few studies 1.
- Intramuscular methylprednisolone may be an effective glucocorticoid-sparing agent, although its long-term benefits and potential side effects are not well established 1.
From the Research
Treatment Options for Polymyalgia Rheumatica
- The standard treatment for polymyalgia rheumatica is steroids, with prednisone or prednisolone being the most commonly used 2, 3, 4, 5.
- Methotrexate is often used as a glucocorticoid-sparing agent, with studies showing its efficacy in reducing the duration of steroid treatment and the cumulative steroid dose 2, 3, 6, 4, 5.
- Biologic agents, such as tocilizumab and sarilumab, have also shown promise in reducing relapse frequency and achieving long-term remission of the disease 3, 4.
Efficacy of Methotrexate
- A study published in 2004 found that the combination of prednisone and methotrexate was more effective than prednisone alone in reducing the duration of steroid treatment and the cumulative steroid dose 2.
- Another study published in 2022 aimed to investigate the efficacy of methotrexate in optimal dose in an early disease phase, with results pending 6.
Biologic Agents
- Anti-IL-6 receptor agents, such as tocilizumab and sarilumab, have demonstrated efficacy in reducing relapse frequency and achieving long-term remission of the disease 3, 4.
- Janus kinase (JAK) inhibitors are also being investigated as a potential treatment option for polymyalgia rheumatica 3, 4.