What causes exacerbation of generalized weakness in Polymyalgia Rheumatica (PMR)?

From the Guidelines

Exacerbation of generalized weakness in Polymyalgia Rheumatica (PMR) is most likely caused by insufficient glucocorticoid doses to suppress inflammation, and treatment should involve temporarily increasing the glucocorticoid dose. The management of PMR should be based on a shared decision between the patient and the treating physician, taking into account the patient's perspective and preferences 1. When managing PMR, it is essential to consider the following key points:

• Adoption of a safe and specific approach to ascertain the PMR case definition, excluding relevant mimicking conditions 1
• Documentation of a basic laboratory dataset to establish a baseline for monitoring therapy and excluding mimicking conditions 1
• Determination of comorbidities, particularly those associated with an increased risk of glucocorticoid-related side effects, such as hypertension, diabetes, and osteoporosis 1
• Consideration of specialist referral, especially in cases of atypical presentation or high risk of therapy-related side effects 1 Some studies suggest that female sex, high erythrocyte sedimentation rate (ESR), and peripheral inflammatory arthritis may be associated with a higher relapse rate and/or prolonged therapy in PMR 1. However, the evidence is not conclusive, and the role of these factors in predicting relapse or prolonged therapy is still unclear 1. In terms of treatment, the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations suggest using the minimum effective dose of glucocorticoids, with a typical starting dose of 12.5-25 mg prednisone equivalent daily 1. Methotrexate may be considered as a steroid-sparing agent, especially in patients with frequent flares or those who are at high risk of glucocorticoid-related side effects 1. Regular follow-up visits are essential to monitor the patient's condition, adjust the treatment plan as needed, and prevent or manage potential side effects 1. Overall, the management of PMR should be individualized, taking into account the patient's specific needs, preferences, and risk factors, and guided by the most recent and highest-quality evidence available 1.

From the Research

Exacerbation of Generalized Weakness in Polymyalgia Rheumatica (PMR)

• The exacerbation of generalized weakness in PMR can be caused by several factors, including:
  • Inadequate treatment or tapering of glucocorticoids too quickly 2, 3
  • Insufficient use of glucocorticoid-sparing agents, such as methotrexate or biologic agents 2, 4
  • Presence of comorbidities, such as giant cell arteritis 3, 5
• The use of glucocorticoids, such as prednisone, is the primary treatment for PMR, but tapering or discontinuation of these drugs can lead to disease relapses 2, 3
• Biologic agents, such as tocilizumab and sarilumab, have shown efficacy in reducing relapse frequency and achieving long-term remission of the disease 2, 4
• Other factors, such as the patient's age and presence of other autoimmune conditions, can also contribute to the exacerbation of generalized weakness in PMR 5
• The erythrocyte sedimentation rate or C reactive protein does not predict relapse 3
• Tenidap has been shown to have steroid-sparing activity in patients with PMR, allowing for reduction or replacement of systemic corticosteroid treatment 6