Polymyalgia Rheumatica Treatment

The treatment of polymyalgia rheumatica (PMR) is aimed at reducing pain and controlling the symptoms. An effective PMR treatment program typically includes glucocorticoid medications in combination with following a healthy lifestyle.

Glucocorticoids (Steroids)

The most commonly prescribed drug for PMR is a type of steroid called glucocorticoid. Glucocorticoid medications reduce inflammation and in turn relieve pain. Prednisone is the most commonly prescribed glucocorticoid and is taken orally. PMR responds very well to low doses of Prednisone (15mg-20mg/day) and most patients can be pain free in 24 to 48 hours from the start of treatment. ¹ Roche NE, Fulbright JW, Wagner AD, Hunder GG, Goronzy JJ, Weyand CM. Correlation of interleukin-6 production and disease activity in polymyalgia rheumatica and giant cell arteritis. Arthritis Rheum. 1993;36:1286-1294. As cited in Weyand CM, Fulbright JW, Evans JM, Hunder GG, Goronzy JJ. Corticosteroid requirements in polymyalgia rheumatica. Arch Intern Med 1999;159:577-84. ^{, 2} Chuang T-Y, Hunder GG, Ilstrup DM, Kurland LT. Polymyalgia rheumatica: a 10- year epidemiologic and clinical study. Ann Intern Med. 1982;97:672-680. As cited in Weyand CM, Fulbright JW, Evans JM, Hunder GG, Goronzy JJ. Corticosteroid requirements in polymyalgia rheumatica. Arch Intern Med 1999;159:577-84. If PMR does not respond to steroid treatment within a few days, the diagnosis should be re-evaluated.

It is advised to start glucocorticoid treatment with the lowest possible dose to lower the risk of side effects. The level of the initial dose depends on the following factors:

• A lower initial dose is typically recommended for patients who have other conditions such as diabetes, osteoporosis, or glaucoma, that increase the risk of steroid-related side effects.
• A higher initial dose may be used for patients who have a higher risk of PMR relapse and a lower risk of steroid-related side effects.

Long-term use of steroids can reduce the effectiveness of the drug. To prevent this negative effect, a process called drug tapering is followed. In drug tapering, the initial dose of the medication is gradually lowered, and the drug is finally discontinued after remission is achieved.

Possible side effects of steroids include:

• Weight gain
• Diabetes
• High blood pressure
• Bone damage due to osteoporosis
• Glaucoma (increased pressure causing damage to the nerves in the eye)

Steroid tapering may also help in preventing these side effects to a large extent.

Calcium and Vitamin D Supplements

A long-term treatment with glucocorticoids can lead to osteoporosis, a condition where bones become brittle and weak. ³ A. Emamifar, Rannveig Gildberg-Mortensen, S. Andreas Just, N. Lomborg, R. Asmussen Andreasen, and I. M. Jensen Hansen, "Level of Adherence to Prophylactic Osteoporosis Medication amongst Patients with Polymyalgia Rheumatica and Giant Cell Arteritis: A Cross-Sectional Study," International Journal of Rheumatology, vol. 2015, Article ID 783709, 5 pages, 2015. Glucocorticoid treatment that lasts longer than 3 months increases the risk of fractures due to osteoporosis by 33% to 50%, depending on the dose of the medication. ⁴ R. M. R. Pereira, J. F. de Carvalho, and E. Canalis, "Glucocorticoid-induced osteoporosis in rheumatic diseases," Clinics, vol. 65, no. 11, pp. 1197–1205, 2010. As cited in - A. Emamifar, Rannveig Gildberg-Mortensen, S. Andreas Just, N. Lomborg, R. Asmussen Andreasen, and I. M. Jensen Hansen, "Level of Adherence to Prophylactic Osteoporosis Medication amongst Patients with Polymyalgia Rheumatica and Giant Cell Arteritis: A Cross-Sectional Study," International Journal of Rheumatology, vol. 2015, Article ID 783709, 5 pages, 2015. To reduce this risk of bone damage, calcium and vitamin D supplements are commonly prescribed during PMR treatment.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are typically not prescribed for PMR. They may be prescribed on a short-term basis for patients who also experience pain from other conditions.

The Importance of Exercise and Diet

An individually customized exercise program is advisable in treating PMR. Maintaining an exercise routine can help with:

• Improving bone health and muscle strength through weight-bearing exercises
• Maintaining joint flexibility through range-of-motion exercises
• Maintaining cardiovascular health through aerobic exercises
• Reducing the risk of falls by improving balance
• Maintaining a healthy weight

See Exercising with Arthritis

Exercise should be performed within tolerated limits. Obtaining adequate rest is necessary to recover from stress due to exercise and daily chores. Eating a healthy and nutritious diet, especially one rich in calcium—can be beneficial in improving overall bone health.

See Ways to Get Exercise When You Have Arthritis

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, may help reduce pain and swelling in the joints. DMARDs may serve as a substitute for glucocorticoids. For example, DMARDs might be prescribed for those who:

• Have a high risk of steroid-related adverse events
• Have other concomitant conditions such as diabetes, osteoporosis, or glaucoma
• Take medications that may interfere with glucocorticoids

Examples of methotrexate include Rheumatrex and Trexall.

Unfortunately, studies using these drugs have failed to show significant efficacy in treating PMR, and therefore are rarely recommended.

Taking medications such as steroids with long-lasting side effects can be challenging. Once the medication starts working and a difference in overall health is seen, patients may lose interest in continuing treatment or stop their medication because of fear regarding side effects. Stopping treatment will almost always result in relapse. Due to the high rate of recurrence of PMR, steroid treatment may be continued for at least 18 to 24 months before discontinuing the drug. ⁵ Behn AR, Perera T, Myles AB. Polymyalgia rheumatica and corticosteroids: how much for how long?Ann Rheum Dis 1983;42:374–8. ^{, 6} Dasgupta B., Borg FA., Hassan N. et al. on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group; BSR and BHPR guidelines for the management of polymyalgia rheumatica, Rheumatology, Volume 49, Issue 1, 1 January 2010, Pages 186–190. ^{, 7} Kyle V, Hazleman BL. Treatment of polymyalgia rheumatica and giant cell arteritis. II. Relation between steroid dose and steroid associated side effects. Annals of the Rheumatic Diseases. 1989;48(8):662-666.

Doctors can educate patients about techniques to help them stay healthy and minimize side effects while on steroid therapy.