Guidelines for the Management of Polymyalgia Rheumatica

A Collaborative Initiative From ACR and EULAR

Hip pain
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Guidelines for the management of polymyalgia rheumatica (PMR) were released in September 2015, as part of a collaborative effort between the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). The guidelines are the first set of international recommendations for the treatment and management of patients with polymyalgia rheumatica. 

What Is Polymyalgia Rheumatica?

It is estimated that about 711,000 American adults have polymyalgia rheumatica -- a condition that usually develops gradually.

While symptoms can develop suddenly, that is not typical of polymyalgia rheumatica. Symptoms include widespread musculoskeletal stiffness, with the hips and shoulders typically involved, as well as the upper arms, neck, and lower back. Usually there is no swelling of the joints. It is possible to have polymyalgia rheumatica along with another rheumatic disease. There has been a wide variation in the treatment of polymyalgia rheumatica, such as when to use glucocorticoids or disease-modifying anti-rheumatic drugs (DMARDs) and for how long. 

Principles and Recommendations for Managing PMR

The 2015 guidelines issued by the ACR and EULAR include overarching principles and specific recommendations pertaining to access to medical care, referral to specialists, patient follow-up, and specific treatment strategies. The specific recommendations were categorized as:

  • "strongly recommended" when evidence pointed to a significant benefit with little to no risk
  • "conditional" when there was little to modest evidence of benefit or when benefit did not significantly outweigh risks

The overarching principles include:

  • Adoption of an approach to ascertain polymalgia rheumatica, with clinical evaluation geared towards excluding conditions that mimic polymyalgia rheumatica.
  • Before prescribing treatment, every case should have documented laboratory test results.
  • Depending on signs and symptoms, additional tests should be ordered to exclude mimicking conditions. Comorbidities should be determined. Risk factors for relapse or prolonged treatment should be considered.
  • Consideration should be given for specialist referral.
  • Treatment decisions should be shared by the patient and physician.
  • Patients should have an individualized treatment plan for polymyalgia rheumatica.
  • Patients should have access to education about polymyalgia rheumatica treatment and management.
  • Every patient being treated for polymyalgia rheumatica should be monitored using specific assessments. In the first year, patients should be seen every 4 to 8 weeks. In the second year, visits should be scheduled every 8-12 weeks. Monitoring should be as needed for relapsing or for prednisone tapering.
  • Patients should have direct access to their health care professionals to report changes, such as flares or adverse events.

    Specific recommendations for the management of polymyalgia rheumatica include:

    • Strong recommendation for the use of glucocorticoids instead of NSAIDs (nonsteroidal anti-inflammatory drugs), except a short-term course of NSAIDs or analgesics in patients with pain related to other conditions.
    • Strong recommendation for the minimum effective individualized duration of glucocorticoid therapy (i.e., use the drug for the shortest amount of time required to obtain an effective response).
    • Conditional recommendation for the minimum effective initial dose of glucocorticoids between 12.5 and 25 mg prednisone equivalent daily. A higher dose may be considered for those at high risk of relapse and low risk of adverse events. A lower dose may be considered for those with comorbidities or risk factors for side effects related to use of glucocorticoids. An initial dose of 7.5 mg/day was conditionally discouraged, and initial doses of 30 mg/day were strongly discouraged.
    • Strong recommendation for individualized tapering schedules and regular monitoring. The suggested schedule for initial tapering is to taper to the oral dose of 10 mg prednisone-equivalent per day within 4 to 8 weeks. For relapse therapy, oral prednisone should be increased to the dose the patient was taking before relapse and then decreased gradually over 4 to 8 weeks to the dose at which the relapse occurred. Once remission is achieved, daily oral prednisone can be tapered by 1 mg every 4 weeks  or by 1.25 mg using an alternate day schedule until the prednisone is discontinued, providing that remission is not disrupted.
    • Conditional recommendation for the use of intramuscular methylprednisolone instead or oral glucocorticoids.
    • Conditional recommendation for a single dose rather than divided daily doses of oral glucocorticoids.
    • Conditional recommendation for the early use of methotrexate in addition to glucocorticoids, especially for certain patients.
    • Strong recommendation against the use of TNF blockers.
    • Conditional recommendation for individualized exercise program to maintain muscle mass and function, as well as reduce the risk of falls.
    • Strong recommendation against the use of Chinese herbal preparations Yanghe and Biqi.

    Sources:

    2015 Recommendations for the Management of Polymyalgia Rheumatica. Dejaco C. et al. Arthritis & Rheumatology Vol. 67 No. 10. October 2015.
    http://www.rheumatology.org/Portals/0/Files/2015%20PMR%20guidelines.pdf

    Polymyalgia Rheumatica. American College of Rheumatology. Updated June 2015.
    http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Polymyalgia-Rheumatica

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