What is polymyalgia rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) should be treated with low-dose corticosteroids, specifically prednisone starting at 12.5-25 mg daily, with a gradual taper over 1-2 years, and regular monitoring of symptoms and inflammatory markers (ESR and CRP) to guide treatment adjustments, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1.

Key Considerations

• The initial prednisone dose should be based on the patient's risk factors for relapse and side effects, with a higher dose (up to 25 mg daily) recommended for patients with a higher risk of relapse and a lower dose (12.5 mg daily) for patients with a higher risk of side effects 1.
• Methotrexate may be added as a steroid-sparing agent, particularly in patients with a high risk of relapse or side effects, as it has been shown to be effective in reducing the cumulative glucocorticoid dose and improving outcomes in PMR patients 1.
• Regular monitoring of symptoms and inflammatory markers (ESR and CRP) is essential to guide treatment adjustments and minimize the risk of relapse and side effects 1.
• Patients with PMR should be educated on the importance of exercise and lifestyle modifications to manage their condition and prevent complications 1.

Treatment Algorithm

• Initial treatment: prednisone 12.5-25 mg daily, with a gradual taper over 1-2 years 1.
• Monitoring: regular assessment of symptoms and inflammatory markers (ESR and CRP) to guide treatment adjustments 1.
• Steroid-sparing agents: methotrexate may be added in patients with a high risk of relapse or side effects 1.
• Relapse therapy: increase dose to the previously effective dose, and consider adding methotrexate if not already used 1.

Prognostic Factors

• Female sex, high ESR, and peripheral inflammatory arthritis have been associated with a higher risk of relapse and prolonged therapy in some studies, but the evidence is not consistent across all studies 1.
• Patients with these risk factors may require closer monitoring and more aggressive treatment to minimize the risk of relapse and side effects.

From the Research

Treatment of Polymyalgia Rheumatica

• The primary treatment for polymyalgia rheumatica (PMR) is corticosteroids, with prednisone being the most commonly used steroid 2, 3, 4.
• The initial dose of prednisone is typically 10-20 mg/day, which yields clinical improvement in the majority of patients with PMR within 7 days 3, 4.
• Methotrexate is often used as a corticosteroid-sparing agent, particularly in patients with relapses or those at high risk for steroid-related toxicity 2, 3, 5, 4.
• The use of methotrexate has been shown to reduce the cumulative prednisone dose and allow for shorter prednisone treatment 2, 5.

Disease Management

• The main goals of PMR treatment are to induce remission and prevent relapse 6.
• Patients with isolated PMR typically experience a rapid response to prednisone treatment, with remission achieved in most patients at a dose of 15 mg/d 4.
• Relapses are not uncommon when the dose of prednisone is reduced to 5 mg/day or lower 3.
• Methotrexate is the most commonly used disease-modifying antirheumatic drug for PMR management, although its effect is often modest 6.

Alternative Therapies

• Anti-interleukin-6 receptor antibody tocilizumab has shown efficacy in PMR in case series and retrospective studies, but controlled trials are needed to fully establish its efficacy 6.
• Janus-kinase inhibitors may have a potential beneficial effect in PMR, but further research is needed to determine their efficacy 6.
• Antitumor necrosis factor agents are not supported by randomized controlled trials for use in PMR 6.