What are the alternative treatment options for polymyalgia rheumatica (PMR) apart from prednisolone?

Alternative Treatment Options for Polymyalgia Rheumatica Beyond Prednisolone

Methotrexate is the most effective and recommended steroid-sparing agent for polymyalgia rheumatica (PMR) when alternatives to prednisolone are needed, with a recommended dosage of 7.5-10 mg weekly. 1

First-Line Alternative: Intramuscular Methylprednisolone

• The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) guidelines conditionally recommend intramuscular (i.m.) methylprednisolone as an alternative to oral glucocorticoids 2
• Dosing regimen:
  • 120 mg every 3 weeks until week 9
  • 100 mg at week 12
  • Monthly injections thereafter with dose reduction of 20 mg every 12 weeks until week 48
  • Then reduction by 20 mg every 16 weeks until discontinuation 1
• This option may be particularly useful for patients who cannot tolerate oral prednisolone or have significant side effects

Second-Line Option: Methotrexate as a Steroid-Sparing Agent

Methotrexate is the most well-established steroid-sparing agent for PMR and should be considered in the following scenarios:

• Patients at high risk for relapse or prolonged therapy
• Patients with risk factors for glucocorticoid-related adverse events
• Patients experiencing inadequate response to glucocorticoids
• Patients with relapse during steroid tapering 2, 1

Methotrexate Evidence and Dosing:

• Recommended dosage: 7.5-10 mg weekly (oral) 2, 1
• Clinical improvement typically noted after 2 weeks, with almost complete response expected after 4 weeks 2
• Randomized controlled trials have demonstrated:
  • Increased likelihood of discontinuing prednisolone (28/32 patients on MTX vs 16/30 on placebo at 76 weeks) 3
  • Reduced frequency of disease flares (15/32 patients on MTX vs 22/30 on placebo) 3
  • Lower cumulative prednisolone dose (2.1g vs 2.97g) 3
  • Preservation of bone mineral density 4

Emerging Biologic Therapies

While TNFα blockers are strongly recommended against by EULAR/ACR guidelines 2, newer research suggests:

• Anti-IL-6 receptor agents (tocilizumab and sarilumab) have shown promise in:
  • Reducing relapse frequency
  • Lowering cumulative glucocorticoid burden
  • Achieving long-term disease remission 5

Treatment Algorithm for PMR Beyond Prednisolone

1. First assessment: Determine if patient is a candidate for alternative therapy

   • Risk factors for steroid-related adverse events (diabetes, osteoporosis, hypertension)
   • History of relapse or prolonged therapy requirement
   • Female sex (higher risk for relapse) 2

2. First alternative option: Consider i.m. methylprednisolone using the dosing regimen outlined above

3. Second alternative option: Add methotrexate 7.5-10 mg weekly to the lowest effective dose of prednisolone

   • Monitor for clinical improvement within 2-4 weeks
   • Continue with gradual prednisolone tapering as tolerated

4. Follow-up monitoring:

   • Every 4-8 weeks in first year
   • Every 8-12 weeks in second year
   • More frequent monitoring during tapering or relapse 1

Important Caveats and Considerations

• The EULAR/ACR guidelines strongly recommend against:

  • TNFα blocking agents for PMR treatment
  • Chinese herbal preparations Yanghe and Biqi capsules 2

• NSAIDs are not recommended as primary treatment for PMR, though they may be used short-term for pain related to other conditions 1

• An individualized exercise program is conditionally recommended to maintain muscle mass and function, particularly important for frail patients and those on long-term glucocorticoids 2, 1

• Atypical presentations, high risk of therapy-related side effects, and refractory disease should prompt specialist referral 1

• Single daily dosing of oral glucocorticoids is preferred over divided doses, except in cases of prominent night pain while on low-dose therapy (<5 mg daily) 2