Continuing Medical Education: Polymyalgia Rheumatica.

Edited By: Gregory C. Gardner, M.D.
Last updated Friday, January 07, 2005

Treatment

How is polymyalgia treated?

The treatment of PMR entails patient education, medications, physical therapy, and prevention of osteoporosis.

Patients with milder disease may respond to NSAIDs alone. Chuang et al were able to treat 30 of 93 PMR patients with NSAIDs and found that these were usually patients with lower initial ESR and milder symptoms (5). Often felt to be more benign than corticosteroids, 3 of the 30 developed GI bleeds (10%).

Most patients will need corticosteroids. The usually dose is 10-20 mg of prednisone in a single daily dose. Most will do well on less than 15 mg/day. If the patient has continued AM stiffness of 15 mg, I like to break the dose into 10 mg in the AM and 5 mg at night rather than increasing the total dose. The night time dose is the first to be tapered. Most patients respond within 24-48 hours often with dramatic relief. The response is diagnostic of the illness and may be helpful in sorting out other possibilities.

The initial dose at which symptoms are controlled is continued for 4-6 weeks and then a slow taper is begun. The prednisone should tapered 1 mg at a time and no faster than 3 mg per month. We are able to taper the corticosteroids because we often over treat initially and because the natural course of the disease causes the symptoms to lessen. It is important to remember that corticosteroids do not cure the illness but only suppress the symptoms until nature takes its course. We often find a level at which the prednisone can not be lowered further and the dose is maintained several weeks to months at that level but the physician and the patient should always be trying to push the dose lower.

Relapses are common and rather than make large jumps in the dose, most patients need only resume their previous dose at which they were comfortable. Remember that most patients will need an average of 2 years of treatment.

An interesting alternative to the usual method of corticosteroid dosing was published in 1991 by Dasgupta et al (9). They treated 16 patients with 120 mg of depomedrol q 3 weeks x 12 then 120 mg q month x 3 and then tapered by 30 mg q 3 months. This resulted in a significantly lower cumulative dose of corticosteroids and no evidence of hypothalamus-pituitary axis suppression as measured at 3 months. At one year, 3 patients developed minor bruising as the only reported side effects and 3 patients dropped out of the protocol. Other agents such as azathioprine, methotrexate, dapsone, and hydroxychloroquine have been used as steroid sparing agents in selected patients.

Finally, physical therapy is useful for treating shoulder capsulitis and rotator cuff weakness that often develops and I have found that patients residual "stiffness" is more often than not mechanical rather than inflammatory in nature. Prednisone can cause a myopathy and a fibromyalgia-like illness that seems to be preventable by gentle aerobic conditioning. Weight bearing exercise also helps prevent osteoporosis. It is important to maintain adequate calcium (1000-1500 mg/day) and vitamin D (400-800u/day). Some authors advocate assessing all patients who will be treated with more than 7 mg of prednisone for more than 3 months with bone densitometry and repeating in 3-6 months as not everybody on corticosteroids will develop osteoporosis and those with preexisting osteoporosis will need close scrutiny from the outset alternatives to standard therapy considered. The American College of Rheumatology has recently developed guidelines for steroid-induced osteoporosis and is available at www.rheumatology.org.

Surgery for arthritis at the University of Washington

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