Polymyalgia Rheumatica Guidelines

Updated: May 30, 2020
  • Author: Ehab R Saad, MD, MA, FACP, FASN; Chief Editor: Herbert S Diamond, MD  more...
  • Print
Guidelines

Guidelines Summary

The following organizations have issued guidelines on the management of polymyalgia rheumatica (PMR):

  • European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR)
  • Italian Society of Rheumatology

Diagnosis

Both the Italian Society of Rheumatology and the joint EULAR/ACR guidelines recommend that following a clinical diagnosis of PMR, an evaluation should be performed to exclude mimicking conditions and to establish a baseline for monitoring therapy. This workup should include the following tests [23, 46] :

  • Rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies (anti-CCP)
  • C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)
  • Complete blood cell count (CBC) with differential
  • Blood glucose
  • Serum creatinine
  • Liver function tests
  • Bone profile (including calcium and alkaline phosphatase)
  • Dipstick urinalysis

Additional studies to consider are as follows [23] :

  • Protein electrophoresis
  • Thyroid-stimulating hormone (TSH)
  • Creatine kinase
  • Vitamin D

If clinically indicated, tests such as the following may be considered to exclude alternative diagnoses [23] :

  • Antinuclear antibodies (ANA)
  • Anti–cytoplasmic neutrophil antibodies (ANCA)
  • Tuberculosis tests
  • Chest radiographs

The Italian Society of Rheumatology also recommends assessing for the following conditions that can affect the management of PMR [46] :

  • Hypertension
  • Diabetes
  • Glucose intolerance
  • Cardiovascular disease
  • Dyslipidemia
  • Peptic ulcer
  • Osteoporosis
  • Cataracts and glaucoma
  • Chronic or recurrent infections
  • Concurrent therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and other medications
  • Risk factors for steroid-related adverse effects

Consultation with a specialist should be considered if the patient has any of the following [46] :

  • An atypical presentation (eg, peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, or age < 60 years)
  • Adverse effects of therapy (or high risk for adverse effects)
  • PMR that resists glucocorticoids, relapses, or requires a prolonged course of treatment

Treatment

The joint EULAR/ACR guidelines include the following key treatment recommendations [23] :

  • Glucocorticoids are the preferred treatment.
  • Short-term NSAIDs and/or analgesics may be used to treat pain related to comorbid conditions such as osteoarthritis.
  • Initial glucocorticoid therapy should be 12.5-25 mg/day of prednisone or the equivalent. 
  • Intramuscular methylprednisolone may be considered as an alternative to oral glucocorticoid therapy.
  • Early introduction of methotrexate (MTX) in addition to glucocorticoid therapy, is conditionally recommended for patients at high risk of relapse and/or prolonged therapy, as well as in those with risk factors for adverse effects of glucocorticoid therapy.
  • Use of MTX may be considered during follow-up in patients with a relapse, lack of a significant response to glucocorticoid therapy, or development of glucocorticoid adverse events.

The Italian Society of Rheumatology guidelines concur with the recommendations for initial glucocorticoid therapy and the addition of MTX in patients at high risk for relapse, prolonged therapy, and/or steroid-related adverse events. [46]

The EULAR/ACR guidelines recommend individualized glucocorticoid dose-tapering schedules, based on regular monitoring of disease activity, laboratory markers, and adverse events. [23]   Both guidelines agree that the target dosages for tapering are 10 mg/day of prednisone or the equivalent within 4-8 weeks. If relapse occurs, increase to the pre-relapse dosage and decrease gradually (within 4-8 weeks) to the dosage at which the relapse occurred. Once remission of PMR is achieved, taper the dosage by 1 mg every 4 weeks (or by 1.25-mg decrements using schedules such as 10/7.5 mg on alternate days) until treatment is discontinued. [23, 46]

The Italian Society of Rheumatology and EULAR/ACR guidelines recommend against the use of tumor necrosis factor alpha (TNF-α) inhibitors. [23, 46]

An exercise program to help maintain muscular mass and function and reduce the risk of falls, particularly in frail patients with PMR and in older patients who are receiving long-term glucocorticoid therapy, is recommended by both guidelines. [23, 46]

Monitoring and Surveillence

The guidelines concur that regular monitoring includes clinical assessment and laboratory studies, on the following schedule [46] :

  • Every 4-8 weeks in the first year of treatment
  • Every 8-12 weeks in the second year
  • As indicated, in case of relapse or as prednisone is tapered off