Management for polymyalgia rheumatica

Dasgupta, 2012Dejaco, 2015Hernandez-Rodriguez, 2009

A long course of a corticosteroid therapy is needed to successfully treat polymyalgia rheumatica and, even with appropriate treatment, relapse is common. Rapid tapering of the corticosteroid dose significantly increases the risk of relapse, which often results in higher overall corticosteroid exposure because increased doses and slower tapering are required to treat relapsed disease. To reduce the risk of relapse, slowly taper the dose of corticosteroid until it can be stopped; smaller and more frequent dose reductions are more effective at preventing relapse than larger and less frequent dose reductions. Tapering regimens shown to reduce the risk of relapse use continuous corticosteroid therapy for 12 months or more; avoid regimens that taper and stop corticosteroid therapy within 9 months.

Note: Avoid corticosteroid regimens for polymyalgia rheumatica that taper and stop within 9 months—treatment is usually required for 12 months or more.
Long-term corticosteroid therapy can cause significant adverse effects. The risk of adverse effects must be balanced against the risk of relapse with inadequate treatment. Use the lowest dose and shortest duration of therapy necessary to control disease and prevent relapse. See Specific considerations for use of systemic corticosteroids for information on adverse effects associated with long-term corticosteroid use (such as bone density loss), and advice on how to minimise and monitor for such complications.

In specific circumstances, a specialist may add methotrexate to corticosteroid therapy for its corticosteroid-sparing effect (see Corticosteroid-sparing therapy for the management of polymyalgia rheumatica).

The use of biological disease-modifying antirheumatic drugs (bDMARDs) is not recommended; evidence suggests they are not as effective as methotrexate in allowing the corticosteroid dose to be reduced in patients with polymyalgia rheumatica. Some studies have shown tocilizumab may be a promising option for management; however, further data are required. There is insufficient evidence available for the use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) other than methotrexate.

In addition to drug therapy, patients should be encouraged to stay active and undertake gentle exercise. The goal of the exercise regimen should be to gradually increase the amount of time spent exercising.