Polymyalgia rheumatica
Polymyalgia rheumatica (PMR) causes pain and stiffness in shoulders, hips, and neck. Treatment uses low-dose glucocorticoids like prednisolone (initially 15 mg daily) with adjustments based on symptoms. Some stop treatment after 1-2 years, while adjunctive medications like methotrexate or tocilizumab may be added for comorbidities or glucocorticoid-related side effects. Physical therapy aids fitness recovery.
Polymyalgia Rheumatica (PMR): Introduction and Association with Giant Cell Arteritis (GCA)
Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition characterised by aching and morning stiffness in the shoulders, hip girdle, and neck. It can be associated with giant cell (temporal) arteritis (GCA); the two disorders may represent different manifestations of a shared disease process. (1, 2)
Primary Goal and Treatment Approach for PMR
The primary goal of treatment is the relief of symptoms of PMR. Treatment is with low dose glucocorticoids. The initial dose of oral prednisolone is usually 15 mg daily. Lower doses of 10 mg daily may suffice in smaller patients with mild symptoms or brittle diabetes. The dose of prednisolone could be escalated to 20- 25mg daily if no significant improvement on the current dose. After aching and stiffness have resolved, glucocorticoid dose that controls symptoms is maintained for two to four weeks.
Glucocorticoid Dosage and Tapering
Thereafter, the dose is reduced by small decrements every two to four weeks as tolerated to the minimum dose needed to maintain suppression of symptoms. In about one- half of patients, treatment can be stopped after one to two years. (3, 4)
Management of Recurrent Symptoms and Relapses
Patients with recurrent symptoms and relapses following discontinuation of glucocorticoids and are accompanied by an elevation in ESR and/or CRP, prednisolone could be resumed at the original dose which managed symptoms. In patients who relapse while on treatment, the glucocorticoid dose is increased to the lowest dose that achieves symptomatic improvement, or the interval between dose reductions can be lengthened to six to eight weeks. (5, 6)
Adjunctive Medications in PMR Treatment
Indications for considering the addition of an adjunctive medication to glucocorticoid therapy include preexisting comorbidities (osteoporosis or decompensated diabetes mellitus), the development of serious glucocorticoid- related side effects, or multiple relapses of symptoms. In these situations, methotrexate (MTX) (10 mg up to 25 mg/week), or tocilizumab (162 mg once every week subcutaneous) can be added. (7)
Non-Pharmacological Measures in PMR
Other non- pharmacological measures include physical therapy which could assist with the restoration of fitness once effective treatment for PMR has been implemented. (8)
References
1- Salvarani CCantini FHunder GG Polymyalgia rheumatica and giant-cell arteritis. Lancet 2008;372 (9634) 234- 245.
2- ird HAEsselinckx WDixon ASMowat AGWood PH An evaluation of criteria for polymyalgia rheumatica. Ann Rheum Dis 1979;38 (5) 434- 439
3- Delecoeuillerie GJoly PCohen de Lara APaolaggi JB Polymyalgia rheumatica and temporal arteritis: a retrospective analysis of prognostic features and different corticosteroid regimens (11 year survey of 210 patients). Ann Rheum Dis 1988;47 (9) 733- 739
4-Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2015; 74:1799.
5- Narváez JNolla-Sole JMClavaguera MTValverde-Garcia JRoig-Escofet D Long-term therapy in polymyalgia rheumatica: effect of coexistent temporal arteritis. J Rheumatol 1999;26 (9) 1945- 1952.
6-Weyand CMFulbright JWEvans JMHunder GGGoronzy JJ Corticosteroid requirements in polymyalgia rheumatica. Arch Intern Med 1999;159 (6) 577- 584
7-Lally L, Forbess L, Hatzis C, Spiera R. Brief Report: A Prospective Open-Label Phase IIa Trial of Tocilizumab in the Treatment of Polymyalgia Rheumatica. Arthritis Rheumatol 2016; 68:2550.
8-Dejaco C, Singh YP, Perel P, et al. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol 2015; 67:2569.
