What is Polymyalgia Rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) should be treated with low-dose corticosteroids, typically prednisone starting at 12.5-25 mg daily, with a gradual tapering over 1-2 years to prevent relapse while minimizing steroid side effects, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1.

Key Considerations

• The initial dose of prednisone should be based on the patient's risk factors for glucocorticoid (GC)-related side effects and relapse/prolonged therapy, 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 be monitored regularly for symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects, with 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.
• Calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements should be taken to prevent osteoporosis, and a bisphosphonate may be needed if on long-term steroids 1.
• Methotrexate may be considered as a GC-sparing agent, particularly in patients with a high risk of relapse or those who experience adverse events with GCs 1.

Prognostic Factors

• Female sex, high erythrocyte sedimentation rate (ESR), and peripheral arthritis have been associated with a higher relapse risk and longer duration of treatment in some studies, but the evidence is not consistent across all studies 1.
• Patients with atypical presentation, such as peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, or age <60 years, should be considered for specialist referral 1.

Treatment Algorithm

• The treatment algorithm should be based on the patient's individualized management plan, taking into account their risk factors, comorbidities, and preferences 1.
• The algorithm should include regular monitoring of symptoms, inflammatory markers, and potential steroid side effects, as well as adjustments to the treatment plan as needed to minimize side effects and prevent relapse 1.

From the Research

Treatment of Polymyalgia Rheumatica

• The standard treatment for polymyalgia rheumatica is steroids, with prednisone being the most commonly used 2, 3, 4.
• The initial dose of prednisone can vary, but 10-20 mg/day is often used, with clinical improvement typically seen within 7 days 3, 5.
• Methotrexate is a commonly used disease-modifying antirheumatic drug for polymyalgia rheumatica, particularly for relapses, but its efficacy is often modest 2, 6, 4.
• The use of antitumor necrosis factor agents is not supported by randomized controlled trials 6.
• Tocilizumab, an anti-interleukin-6 receptor antibody, has shown efficacy in some case series and retrospective studies, but controlled trials are needed to fully establish its effectiveness 6.

Factors Influencing Treatment Response

• Body weight is a significant predictor of response to prednisone, with lower weight patients more likely to respond to a starting dose of 12.5 mg/day 5.
• Gender may also play a role, with women more likely to respond to prednisone due to their lower weight 5.
• Disease severity does not appear to influence the starting dose of prednisone 5.

Treatment Outcomes

• Prednisone plus methotrexate has been shown to be associated with shorter prednisone treatment and steroid sparing 2.
• Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation 4.
• The cumulative prednisone dose can be reduced with the use of methotrexate 2, 4.