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.
- Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology (Oxford) 2010; 49:186.
- 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.
- 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.
- Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA 2016; 315:2442.
- Hernández-Rodríguez J, Cid MC, López-Soto A, et al. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med 2009; 169:1839.
- Dejaco C, Singh YP, Perel P, et al. Current evidence for therapeutic interventions and prognostic factors in polymyalgia rheumatica: a systematic literature review informing the 2015 European League Against Rheumatism/American College of Rheumatology recommendations for the management of polymyalgia rheumatica. Ann Rheum Dis 2015; 74:1808.
- Cimmino MA, Parodi M, Montecucco C, Caporali R. The correct prednisone starting dose in polymyalgia rheumatica is related to body weight but not to disease severity. BMC Musculoskelet Disord 2011; 12:94.
- Salvarani C, Pipitone N, Versari A, Hunder GG. Clinical features of polymyalgia rheumatica and giant cell arteritis. Nat Rev Rheumatol 2012; 8:509.
- Roche NE, Fulbright JW, Wagner AD, et al. Correlation of interleukin-6 production and disease activity in polymyalgia rheumatica and giant cell arteritis. Arthritis Rheum 1993; 36:1286.
- Alvarez-Rodríguez L, Lopez-Hoyos M, Mata C, et al. Circulating cytokines in active polymyalgia rheumatica. Ann Rheum Dis 2010; 69:263.
- McCarthy EM, MacMullan PA, Al-Mudhaffer S, et al. Plasma fibrinogen is an accurate marker of disease activity in patients with polymyalgia rheumatica. Rheumatology (Oxford) 2013; 52:465.
- Kremers HM, Reinalda MS, Crowson CS, et al. Relapse in a population based cohort of patients with polymyalgia rheumatica. J Rheumatol 2005; 32:65.
- Salvarani C, Cantini F, Niccoli L, et al. Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum 2005; 53:33.
- González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, et al. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol 1999; 26:1326.
- Weyand CM, Fulbright JW, Evans JM, et al. Corticosteroid requirements in polymyalgia rheumatica. Arch Intern Med 1999; 159:577.
- Pulsatelli L, Boiardi L, Pignotti E, et al. Serum interleukin-6 receptor in polymyalgia rheumatica: a potential marker of relapse/recurrence risk. Arthritis Rheum 2008; 59:1147.
- Salvarani C, Cantini F, Macchioni P, et al. Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum 1998; 41:1221.
- Chuang TY, Hunder GG, Ilstrup DM, Kurland LT. Polymyalgia rheumatica: a 10-year epidemiologic and clinical study. Ann Intern Med 1982; 97:672.
- Ayoub WT, Franklin CM, Torretti D. Polymyalgia rheumatica. Duration of therapy and long-term outcome. Am J Med 1985; 79:309.
- Cimmino MA, Salvarani C, Macchioni P, et al. Long-term follow-up of polymyalgia rheumatica patients treated with methotrexate and steroids. Clin Exp Rheumatol 2008; 26:395.
- Docken WP. Polymyalgia rheumatica can recur years after discontinuation of corticosteroid therapy. Clin Exp Rheumatol 2009; 27:S25.
- Gabriel SE, Sunku J, Salvarani C, et al. Adverse outcomes of antiinflammatory therapy among patients with polymyalgia rheumatica. Arthritis Rheum 1997; 40:1873.
- Feinberg HL, Sherman JD, Schrepferman CG, et al. The use of methotrexate in polymyalgia rheumatica. J Rheumatol 1996; 23:1550.
- Ferraccioli G, Salaffi F, De Vita S, et al. Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol 1996; 23:624.
- Caporali R, Cimmino MA, Ferraccioli G, et al. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2004; 141:493.
- van der Veen MJ, Dinant HJ, van Booma-Frankfort C, et al. Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis? Ann Rheum Dis 1996; 55:218.
- Salvarani C, Macchioni P, Manzini C, et al. Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial. Ann Intern Med 2007; 146:631.
- Kreiner F, Galbo H. Effect of etanercept in polymyalgia rheumatica: a randomized controlled trial. Arthritis Res Ther 2010; 12:R176.
- Catanoso MG, Macchioni P, Boiardi L, et al. Treatment of refractory polymyalgia rheumatica with etanercept: an open pilot study. Arthritis Rheum 2007; 57:1514.
- Corrao S, Pistone G, Scaglione R, et al. Fast recovery with etanercept in patients affected by polymyalgia rheumatica and decompensated diabetes: a case-series study. Clin Rheumatol 2009; 28:89.
- Macchioni P, Boiardi L, Catanoso M, et al. Tocilizumab for polymyalgia rheumatica: report of two cases and review of the literature. Semin Arthritis Rheum 2013; 43:113.
- Lally L, Forbess L, Hatzis C, Spiera R. A Prospective Open Label Phase IIa Trial of Tocilizumab In the Treatment of Polymyalgia Rheumatica. Arthritis Rheumatol 2016.
- Devauchelle-Pensec V, Berthelot JM, Cornec D, et al. Efficacy of first-line tocilizumab therapy in early polymyalgia rheumatica: a prospective longitudinal study. Ann Rheum Dis 2016; 75:1506.
- Doran MF, Crowson CS, O'Fallon WM, et al. Trends in the incidence of polymyalgia rheumatica over a 30 year period in Olmsted County, Minnesota, USA. J Rheumatol 2002; 29:1694.
- 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