Cyclobenzaprine is NOT Appropriate for Polymyalgia Rheumatica
Cyclobenzaprine should not be used to treat polymyalgia rheumatica—glucocorticoids are the only strongly recommended first-line therapy, with prednisone 12.5-25 mg daily as the initial treatment. 1
Why Cyclobenzaprine Has No Role in PMR
Disease Mechanism Mismatch
- PMR is an inflammatory condition requiring anti-inflammatory therapy, not muscle relaxation 1
- Cyclobenzaprine is a muscle relaxant evaluated only for fibromyalgia (a non-inflammatory pain syndrome), where it showed minimal benefit—only improving sleep slightly (SMD 0.34) with no pain reduction 1
- The pathophysiology of PMR involves systemic inflammation affecting proximal muscle groups and requires suppression of inflammatory pathways, which cyclobenzaprine does not address 1
Guideline-Directed Therapy for PMR
- The EULAR/ACR 2015 guidelines strongly recommend glucocorticoids instead of NSAIDs or other analgesics as primary therapy 1
- Initial prednisone dosing should be 12.5-25 mg daily, with individualization based on relapse risk and comorbidities 1
- The guidelines explicitly state that NSAIDs may only be used short-term for pain related to other conditions (not PMR itself), and make no specific recommendation for analgesics 1
Poor Risk-Benefit Profile of Cyclobenzaprine
- In fibromyalgia trials, 85% of patients experienced side effects and only 71% completed studies 1
- The number needed to treat for self-reported improvement was 4.8, with very modest effects 1
- These marginal benefits in a non-inflammatory condition would be even less relevant in PMR, where inflammation must be controlled 1
The Correct Treatment Approach
First-Line Glucocorticoid Therapy
- Start prednisone 12.5-25 mg daily (higher end for high relapse risk, lower end for patients with diabetes, osteoporosis, or glaucoma) 1
- Taper to 10 mg daily within 4-8 weeks if responding 1
- Continue tapering by 1 mg every 4 weeks once remission is achieved 1
Glucocorticoid-Sparing Options When Needed
- Methotrexate 7.5-10 mg weekly should be considered early for patients at high risk for relapse, prolonged therapy, or glucocorticoid-related adverse events 1, 2, 3
- Tocilizumab and sarilumab (anti-IL-6 receptor agents) have demonstrated efficacy in reducing relapse frequency and cumulative glucocorticoid burden in glucocorticoid-resistant cases 3, 4, 5
- Anti-TNF agents are strongly recommended against, as they have failed to show benefit in isolated PMR 1
Common Pitfall to Avoid
Do not confuse PMR with fibromyalgia or other non-inflammatory pain syndromes. PMR requires aggressive anti-inflammatory therapy with glucocorticoids to prevent disease progression and reduce morbidity 1. Using muscle relaxants or analgesics as primary therapy will result in inadequate disease control, prolonged symptoms, and potentially higher cumulative glucocorticoid exposure when treatment is eventually escalated 2.