NEJM: Polymyalgia Rheumatica Save

Drs. Dejaco and Matteson have published and update and review of polymyalgia rheumatica (PMR) in the NEJM. They lay out the initial approach to diagnosis, initial steroid dosing, management over time and when to use steroid sparing therapy.

The authors use a case discussion to review the tenets of PMR management -- A 74-year-old woman with diabetes mellitus presents with 6 weeks of progressive pain in the shoulders and neck, fatigue, and pronounced morning stiffness. Examination is finds tenderness in the muscles of both upper arms, but no joint swelling or tenderness. Her erythrocyte sedimentation rate (ESR) is 67 mm in the first hour (normal value, <20 mm per hour), C-reactive protein (CRP) level 2.35 mg per deciliter (normal value, <0.5 mg per deciliter), and glycated hemoglobin level 6.8%, and she has a mild normochromic, normocytic anemia. 

How should the patient be evaluated and treated?

Important teaching points:

• Persons of northern European descent have the highest incidence, with 34 to 113 new cases per 100,000
• There is no specific test for polymyalgia rheumatica.
• Glucocorticoids are the mainstay of treatment.
• The initial dose is 12.5 to 25 mg of prednisone equivalent daily, which is tapered off within 12 months or less.The initial response to treatment is typically rapid
• Relapses occur in approximately 40% of patients during the tapering of glucocorticoids.
• An interleukin-6 receptor inhibitor (i.e., sarilumab or tocilizumab) should be considered in selected patients to reduce the cumulative glucocorticoid dose. Methotrexate might be an alternative

Uncertainties

• Role of imaging for PMR is unsettled
• Should PMR be diagnosed and managed by general practitioners or a specialist (rheumatologist)
• Consensus on when to escalate steroids to IL-6 inhibition in PMR