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{{Polymyalgia rheumatica}}
{{Polymyalgia rheumatica}}
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==Overview==
==Overview==
The mainstay of treatment of polymyalgia rheumatica (PMR) is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]]. The starting dose of the [[glucocorticoid]] treatment is 15-20 mg daily for 2 to 4 weeks after which the treatment should be slowly tapered. The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms. Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started with the [[steroid]] therapy.
The mainstay of treatment of polymyalgia rheumatica (PMR) is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]]. The starting dose of the [[glucocorticoid]] treatment is 12.5-15 mg daily for 2 to 4 weeks after which the treatment should be slowly tapered. The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms. Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started with the [[steroid]] therapy.


==Medical Therapy==
==Medical Therapy==
* The mainstay of treatment of PMR is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]]:
* The mainstay of treatment of PMR is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]].<ref name="pmid23051717">{{cite journal| author=Kermani TA, Warrington KJ| title=Polymyalgia rheumatica. | journal=Lancet | year= 2013 | volume= 381 | issue= 9860 | pages= 63-72 | pmid=23051717 | doi=10.1016/S0140-6736(12)60680-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23051717  }} </ref>
** The starting dose is 15-20 mg daily for 2 to 4 weeks
** Gradually taper the [[steroid]] by decreasing the dose by 2.5 mg every 2 to 4 weeks
** When the dose is 10 mg daily, decrease the dose by 1 mg every month


* There should be close attention to the occurrence of symptoms of [[giant cell arteritis]]. Higher dose of [[glucocorticoids]] (40 mg daily) is indicated when patients with PMR develop [[giant cell arteritis]]
* The symptoms resolution begins within a few days after the initiation of the treatment, and this improvement of the symptoms reinforces the diagnosis of PMR.<ref name="pmid23051717">{{cite journal| author=Kermani TA, Warrington KJ| title=Polymyalgia rheumatica. | journal=Lancet | year= 2013 | volume= 381 | issue= 9860 | pages= 63-72 | pmid=23051717 | doi=10.1016/S0140-6736(12)60680-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23051717  }} </ref>
* During the treatment, the subject's response to treatment should be monitored through:
 
** Clinical symptoms
* During the treatment, the subject's response to treatment should be monitored through clinical symptoms and measurement of [[ESR]] or [[CRP]].
** Measurement of [[ESR]] and [[CRP]]


* Treatment lasts as long as needed; however, it normally takes patients several years to get off of the [[steroids]]. The symptoms may come back when the dosage is lowered.  The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms.
* Treatment lasts as long as needed; however, it normally takes patients several years to get off of the [[steroids]]. The symptoms may come back when the dosage is lowered.  The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms.


* Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]]. The doctor should be notified of any signs of sickness.
* Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]].
* Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started along with [[steroid]] therapy.
* Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started along with [[steroid]] therapy.
* [[Infliximab]] use in [[PMR]] has not been proved beneficial and it may be harmful.<ref name="pmid17470831">{{cite journal |author=Salvarani C, Macchioni P, Manzini C, ''et al.'' |title=Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=9 |pages=631–9 |year=2007 |month=May |pmid=17470831 |doi= |url=}}</ref>


=== Other therapies ===
=== Polymyalgia rheumatica ===
*[[Methotrexate]] is the commonly used steroid sparing agent.  [[Prednisone]] plus [[methotrexate]] treatment is associated with shorter [[prednisone]] treatment.<ref name="pmid15466766">{{cite journal |author=Caporali R, Cimmino MA, Ferraccioli G, ''et al.'' |title=Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=7 |pages=493–500 |year=2004 |month=October |pmid=15466766 |doi= |url=}}</ref>
* '''1 Glucocorticoids'''
 
** Preferred regimen (1): [[Prednisone]] 12.5-15 mg PO qd for 2-4 weeks (maximum 40 mg/d) then taper it by decreasing the dose by 2.5 mg every 2 to 4 weeks till reaches 10 mg, then decrease the dose by 1 mg every month
*[[Infliximab]] use in [[PMR]] has not been proved beneficial and it may be harmful.<ref name="pmid17470831">{{cite journal |author=Salvarani C, Macchioni P, Manzini C, ''et al.'' |title=Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=9 |pages=631–9 |year=2007 |month=May |pmid=17470831 |doi= |url=}}</ref>
* '''2 Glucocorticoid-sparing therapies'''
 
** Alternative regimen (1): [[Methotrexate]] 10 mg PO every week<ref name="pmid15466766">{{cite journal |author=Caporali R, Cimmino MA, Ferraccioli G, ''et al.'' |title=Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=7 |pages=493–500 |year=2004 |month=October |pmid=15466766 |doi= |url=}}</ref>
*[[Etanercept]] may be safe and useful in relapsing [[PMR]]. It is modestly effective in [[PMR]] associated with [[giant cell arteritis]] than in isolated [[PMR]].  Trials are still in progress to determine the benefit and the differences in response.
** Alternative regimen (2): [[Etanercept]] 25 mg SC twice weekly


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
 
{{WS}}
[[Category:Medicine]]
[[Category:Disease]]
[[Category:Rheumatology]]
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Latest revision as of 23:47, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The mainstay of treatment of polymyalgia rheumatica (PMR) is low dose glucocorticoids, typically prednisone or prednisolone. The starting dose of the glucocorticoid treatment is 12.5-15 mg daily for 2 to 4 weeks after which the treatment should be slowly tapered. The average duration of the treatment with glucocorticoids is 1 to 2 years; nevertheless, longer corticosteroids regimens might be necessary among patients who experience relapse of the symptoms. Prophylaxis for osteoporosis with calcium and vitamin D should be started with the steroid therapy.

Medical Therapy

  • The symptoms resolution begins within a few days after the initiation of the treatment, and this improvement of the symptoms reinforces the diagnosis of PMR.[1]
  • During the treatment, the subject's response to treatment should be monitored through clinical symptoms and measurement of ESR or CRP.
  • Treatment lasts as long as needed; however, it normally takes patients several years to get off of the steroids. The symptoms may come back when the dosage is lowered. The average duration of the treatment with glucocorticoids is 1 to 2 years; nevertheless, longer corticosteroids regimens might be necessary among patients who experience relapse of the symptoms.

Polymyalgia rheumatica

  • 1 Glucocorticoids
    • Preferred regimen (1): Prednisone 12.5-15 mg PO qd for 2-4 weeks (maximum 40 mg/d) then taper it by decreasing the dose by 2.5 mg every 2 to 4 weeks till reaches 10 mg, then decrease the dose by 1 mg every month
  • 2 Glucocorticoid-sparing therapies

References

  1. 1.0 1.1 Kermani TA, Warrington KJ (2013). "Polymyalgia rheumatica". Lancet. 381 (9860): 63–72. doi:10.1016/S0140-6736(12)60680-1. PMID 23051717.
  2. Salvarani C, Macchioni P, Manzini C; et al. (2007). "Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial". Ann. Intern. Med. 146 (9): 631–9. PMID 17470831. Unknown parameter |month= ignored (help)
  3. Caporali R, Cimmino MA, Ferraccioli G; et al. (2004). "Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial". Ann. Intern. Med. 141 (7): 493–500. PMID 15466766. Unknown parameter |month= ignored (help)