How to manage a patient with polymyalgia or polyarthritis?

Management of Polymyalgia Rheumatica and Polyarthritis

Polymyalgia Rheumatica (PMR)

Glucocorticoids are the cornerstone of treatment for polymyalgia rheumatica, with prednisone 12.5-25 mg daily as the initial therapy, NOT analgesics, vitamins, or exercise alone. 1, 2

Initial Treatment Approach

• Start prednisone at 12.5-25 mg daily (oral), with higher doses (closer to 25 mg) reserved for patients at high risk of relapse and low risk of adverse events 1, 2
• Expect rapid clinical improvement within 3-7 days; lack of response should prompt reconsideration of the diagnosis 3, 4
• NSAIDs alone are insufficient and should NOT be used as monotherapy for PMR 1, 5

Pre-Treatment Workup (Mandatory)

Before starting glucocorticoids, obtain: 1

• Inflammatory markers: ESR and/or CRP (typically markedly elevated)
• Exclusion labs: Rheumatoid factor, anti-CCP antibodies, complete blood count
• Baseline monitoring: Glucose, creatinine, liver function tests, calcium, alkaline phosphatase, urinalysis
• Additional considerations: Vitamin D, TSH, creatine kinase, protein electrophoresis

Glucocorticoid Tapering Strategy

• Taper slowly over 12-18 months with close monitoring every 4-8 weeks during the first year 2, 5
• Relapses are common (occurring in up to 50% of patients), requiring dose adjustments 1
• Risk factors for relapse include: female sex, ESR >40 mm/hr at diagnosis, and peripheral inflammatory arthritis 2, 6

Glucocorticoid-Related Monitoring

Assess and manage glucocorticoid complications: 2

• Screen for hypertension, diabetes, dyslipidemia, peptic ulcer disease
• Implement osteoporosis prevention (calcium, vitamin D, bisphosphonates if indicated)
• Monitor for cardiovascular disease risk

Steroid-Sparing Agents (For Refractory or Relapsing Disease)

• Methotrexate may be considered as an adjunct in patients with high relapse risk, glucocorticoid-related adverse effects, or inability to taper steroids 3, 4, 7
• Evidence for methotrexate shows only modest benefit in PMR 7
• Tocilizumab (anti-IL-6 receptor) shows promise in case series for refractory PMR, though controlled trials are needed 7

What Does NOT Work

• Analgesics alone are inadequate for managing the inflammatory process 1
• Vitamins have no role in treating the underlying disease (though vitamin D supplementation is important for bone health during glucocorticoid therapy) 1
• NSAIDs as monotherapy are ineffective and not recommended 1, 5

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Polyarthritis Management

For inflammatory polyarthritis, DMARDs such as methotrexate are strongly recommended over NSAID monotherapy, as NSAIDs alone do not prevent joint damage or modify disease progression. 8

First-Line Treatment

• NSAIDs (e.g., naproxen) may be used as adjunct therapy for symptom management only, not as primary treatment 8
• NSAID monotherapy is inappropriate for persistent inflammatory arthritis 8

Second-Line Treatment (Primary Disease-Modifying Therapy)

• Methotrexate is the preferred DMARD over alternatives like leflunomide or sulfasalazine 8, 9
• Subcutaneous methotrexate is preferred over oral for better bioavailability 8
• Short-term oral glucocorticoids may be used as bridging therapy during DMARD initiation in patients with moderate-to-high disease activity 8
• Intra-articular glucocorticoid injections (triamcinolone hexacetonide preferred over acetonide) can be used as adjunct therapy 8
• Chronic low-dose glucocorticoids are strongly recommended against regardless of disease activity 8

Third-Line Treatment (Refractory Cases)

• For persistent moderate/high disease activity despite DMARD therapy, adding a biologic agent to the original DMARD is preferred over switching to a second DMARD 8
• If a first TNF inhibitor fails, switch to a non-TNF biologic (tocilizumab or abatacept) rather than a second TNF inhibitor 8

Non-Pharmacological Interventions

• Physical therapy and/or occupational therapy are recommended for patients with or at risk for functional limitations 8
• Regular exercise helps maintain muscle mass and function, particularly important during glucocorticoid therapy 1
• No specific dietary interventions or food supplements (including fish oil) have proven efficacy for disease modification 1

Monitoring

• Use validated disease activity tools (e.g., cJADAS-10 for inflammatory arthritis) 8
• Monitor for medication side effects: hepatotoxicity with methotrexate, gastrointestinal effects with NSAIDs 8, 9

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Critical Distinction: PMR vs. Polyarthritis

PMR and seronegative polyarthritis may represent overlapping conditions in elderly patients, with some presenting initially as PMR and later developing peripheral synovitis 10. Both respond to glucocorticoids, but true inflammatory polyarthritis requires DMARD therapy to prevent joint destruction 8, 10.

Red Flags Requiring Specialist Referral

• Atypical presentations: peripheral arthritis, systemic symptoms, low inflammatory markers, age <60 years 2
• Poor response to appropriate glucocorticoid dosing within 1 week 3, 4
• Frequent relapses or inability to taper glucocorticoids 2