Polymyalgia Rheumatica Medication
- Author: Ehab R Saad, MD, MA, FACP, FASN; Chief Editor: Herbert S Diamond, MD more...
The goals of therapy in polymyalgia rheumatica (PMR) are to control painful myalgia, to improve muscle stiffness, and to resolve constitutional features of the disease. Oral corticosteroids are the first line of treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful as adjuncts to corticosteroids during tapering, or alone in mild cases; however, because they are associated with increased drug-related morbidity, they should be used with caution, especially in elderly patients.
These agents cause profound and varied metabolic effects. Their exact mechanism of action in PMR is not well known, but their efficacy may stem from their general anti-inflammatory and immunomodulatory effects. In addition, corticosteroids down-regulate cytokine production.
Prednisone has the capacity to dramatically reduce inflammatory manifestations for the following reasons:
Polymyalgia rheumatica is rapidly responsive to low doses of prednisone. However, patients may require treatment for several months to several years.
Nonsteroidal Anti-Inflammatory Drugs
These agents can be administered to some patients with mild symptoms; however, patients require corticosteroids for total control of symptoms. NSAIDs may be helpful in later stages of corticosteroid dosage tapering, with close monitoring for drug-related morbidity. NSAIDs generally have no effect on the ESR.
Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen is indicated for relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Antineoplastic agent that is immunosuppressive at lower doses. Antirheumatic effects may take several weeks to become apparent. Unknown mechanism of action in treatment of inflammatory disorders; may affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness).
Gonzalez-Gay MA, Barros S, Lopez-Diaz MJ, Garcia-Porrua C, Sanchez-Andrade A, Llorca J. Giant cell arteritis: disease patterns of clinical presentation in a series of 240 patients. Medicine (Baltimore). 2005 Sep. 84(5):269-76. [Medline].
Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, et al. Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009 Oct 15. 61(10):1454-61. [Medline].
Ghosh P, Borg FA, Dasgupta B. Current understanding and management of giant cell arteritis and polymyalgia rheumatica. Expert Rev Clin Immunol. 2010 Nov. 6(6):913-28. [Medline].
Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013 Nov 15. 88(10):676-84. [Medline].
Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008 Jul 19. 372(9634):234-45. [Medline].
Martinez-Taboada VM, Alvarez L, RuizSoto M, Marin-Vidalled MJ, Lopez-Hoyos M. Giant cell arteritis and polymyalgia rheumatica: role of cytokines in the pathogenesis and implications for treatment. Cytokine. 2008 Nov. 44(2):207-20. [Medline].
Gonzalez-Gay MA, Garcia-Porrua C, Miranda-Filloy JA, Martin J. Giant cell arteritis and polymyalgia rheumatica: pathophysiology and management. Drugs Aging. 2006. 23(8):627-49. [Medline].
Wilke WS. The role of imaging in polymyalgia rheumatica/giant cell arteritis. Skeletal Radiol. 2008 Sep. 37(9):779-83. [Medline].
Blockmans D. PET in vasculitis. Ann N Y Acad Sci. 2011 Jun. 1228:64-70. [Medline].
Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med. 2002 Jul 25. 347(4):261-71. [Medline].
Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum. 1984 May. 13(4):322-8. [Medline].
Macchioni P, Boiardi L, Catanoso M, Pazzola G, Salvarani C. Performance of the new 2012 EULAR/ACR classification criteria for polymyalgia rheumatica: comparison with the previous criteria in a single-centre study. Ann Rheum Dis. 2013 Dec 2. [Medline].
Dasgupta B, Cimmino MA, Maradit-Kremers H, Schmidt WA, Schirmer M, Salvarani C, et al. 2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2012 Apr. 71(4):484-92. [Medline].
Salvarani C, Cantini F, Macchioni P, Olivieri I, Niccoli L, Padula A, et al. Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 1998 Jul. 41(7):1221-6. [Medline].
[Guideline] 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 Oct. 74 (10):1799-807. [Medline]. [Full Text].
Cantini F, Salvarani C, Olivieri I, et al. Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica: a prospective follow-up study. Semin Arthritis Rheum. 2000 Aug. 30(1):17-24. [Medline].
van der Geest KS, Abdulahad WH, Rutgers A, Horst G, Bijzet J, Arends S, et al. Serum markers associated with disease activity in giant cell arteritis and polymyalgia rheumatica. Rheumatology (Oxford). 2015 Aug. 54 (8):1397-402. [Medline].
Ochi J, Nozaki T, Okada M, Suyama Y, Kishimoto M, Akaike G, et al. MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica. Mod Rheumatol. 2015 Sep. 25 (5):761-7. [Medline].
Matteson EL, Maradit-Kremers H, Cimmino MA, Schmidt WA, Schirmer M, Salvarani C, et al. Patient-reported Outcomes in Polymyalgia Rheumatica. J Rheumatol. 2012 Apr. 39(4):795-803. [Medline].
Hernández-Rodríguez J, Cid MC, López-Soto A, Espigol-Frigolé G, Bosch X. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med. 2009 Nov 9. 169(20):1839-50. [Medline].
Dejaco C, Duftner C, Cimmino MA, et al. Definition of remission and relapse in polymyalgia rheumatica: data from a literature search compared with a Delphi-based expert consensus. Ann Rheum Dis. 2011 Mar. 70(3):447-53. [Medline]. [Full Text].
Leeb BF, Bird HA, Nesher G, et al. EULAR response criteria for polymyalgia rheumatica: results of an initiative of the European Collaborating Polymyalgia Rheumatica Group (subcommittee of ESCISIT). Ann Rheum Dis. 2003 Dec. 62(12):1189-94. [Medline]. [Full Text].
Gabriel SE, Sunku J, Salvarani C, O'Fallon WM, Hunder GG. Adverse outcomes of antiinflammatory therapy among patients with polymyalgia rheumatica. Arthritis Rheum. 1997 Oct. 40(10):1873-8. [Medline].
van der Veen MJ, Dinant HJ, van Booma-Frankfort C, van Albada-Kuipers GA, Bijlsma JW. Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis?. Ann Rheum Dis. 1996 Apr. 55(4):218-23. [Medline]. [Full Text].
Caporali R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, et al. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2004 Oct 5. 141(7):493-500. [Medline].
Ferraccioli G, Salaffi F, De Vita S, Casatta L, Bartoli E. Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol. 1996 Apr. 23(4):624-8. [Medline].
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 May 1. 146(9):631-9. [Medline].
González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, Dababneh A, Hajeer A, Ollier WE. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol. 1999 Jun. 26(6):1326-32. [Medline].