Treatment of polymyalgia rheumatica
- William P Docken, MD
William P Docken, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Section Editors
- Gene G Hunder, MD
Gene G Hunder, MD
- Section Editor — Vasculitis
- Emeritus Consultant
- Professor Emeritus
- Mayo Clinic College of Medicine
- Eric L Matteson, MD, MPH
Eric L Matteson, MD, MPH
- Section Editor — Treatment Issues in Rheumatology
- Chair, Division of Rheumatology
- Professor of Medicine
- Mayo Clinic College of Medicine
Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition characterized clinically by aching and morning stiffness about 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. Some patients have manifestations of both disorders occurring at different times. (See "Clinical manifestations and diagnosis of polymyalgia rheumatica".)
The treatment of PMR will be reviewed here. Additional issues pertaining to PMR, as well as the clinical manifestations, diagnosis, and treatment of GCA, are discussed separately. (See "Clinical manifestations and diagnosis of polymyalgia rheumatica" and "Clinical manifestations of giant cell (temporal) arteritis" and "Diagnosis of giant cell (temporal) arteritis" and "Treatment of giant cell (temporal) arteritis".)
Polymyalgia rheumatica (PMR) is characterized by a prompt response to glucocorticoids in low to moderate doses. The initial dose of prednisone needed to alleviate musculoskeletal symptoms in PMR is lower than that required to control the vascular inflammation associated with giant cell (temporal) arteritis (GCA). (See "Treatment of giant cell (temporal) arteritis".)
General guidelines — We recommend treatment with glucocorticoids as initial therapy in patients diagnosed with PMR. The primary goal of therapy is the relief of symptoms. Therapy has not been shown to clearly improve prognosis or prevent progression to GCA.
The value of glucocorticoids in the treatment of PMR has been established by decades of clinical experience and observational studies. Though we are not aware of any controlled trials comparing prednisone or prednisolone with placebo or other single agents, the brisk and dramatic therapeutic response to low-dose glucocorticoids remains a widely appreciated feature of PMR. Some patients with PMR may experience symptomatic improvement after only one or two doses of glucocorticoids, and the vast majority of such patients experience a marked improvement in symptoms within days of starting treatment, despite experiencing longstanding symptoms. Medications other than glucocorticoids, such as methotrexate (MTX) or tumor necrosis factor (TNF) inhibitors, have not conclusively been proven effective in PMR. Nonsteroidal antiinflammatory drugs (NSAIDs) have no role in the primary management of PMR.
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- OVERALL APPROACH
- General guidelines
- Baseline laboratory testing
- INITIAL GLUCOCORTICOID THERAPY
- Alternative initial therapies
- MAINTENANCE PHASE AND DOSE REDUCTION
- MONITORING RESPONSE TO THERAPY
- Symptomatic patients
- The problematic glucocorticoid taper
- Abnormal testing without symptoms
- DURATION OF TREATMENT
- SIDE EFFECTS OF GLUCOCORTICOIDS
- GLUCOCORTICOID-SPARING THERAPIES
- TNF inhibitors
- - Infliximab
- - Etanercept
- IL-6 receptor blockade
- OTHER THERAPIES
- Physical therapy
- Nonsteroidal antiinflammatory drugs
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS