Polymyalgia rheumatica medical therapy: Difference between revisions

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==Overview==
==Overview==
The mainstay of treatment of polymyalgia rheumatica (PMR) is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]]. The starting dose of the [[glucocorticoid]] treatment is 12.5-15 mg daily for 2 to 4 weeks after which the treatment should be slowly tapered. The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms. Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started with the [[steroid]] therapy.
==Medical Therapy==
==Medical Therapy==
Anti-inflammatory medicine such as [[aspirin]] or [[ibuprofen]] is typically prescribed to treat mild cases of [[polymyalgia rheumatica]]. For more serious cases, with extreme pain and discomfort, [[steroids]] are prescribed to patients. [[Prednisone]] is the typical [[steroid]] used to treat [[polymyalgia rheumatica]]. The [[steroids]] are normally distributed in low doses (10-15 mg per day), and results are usually seen within the first few days of taking the medication.<ref name="citation4">http://www.rheumatology.org/public/factsheets/pmr_new2.asp "POLYMYALGIA RHEUMATICA." American College of Rheumatology. June 2006. American College of Rheumatology. 11 Mar. 2008 </ref> The patient's SED rate is monitored throughout the medication process, and other [[blood tests]] are conducted to make sure the patient does not experience any side effects from the treatment. Once the SED rate is back to normal, the patient will receive lower doses of the [[steroids]] in order to avoid any long term health effects from the [[steroids]].<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008  </ref> [[Intramuscular]] [[methylprednisolone]](40-120 mg)has similar effects like oral [[corticosteroids]] and the cumulative steroid dose is also less.<ref name="pmid1768166">{{cite journal |author=Dasgupta B, Gray J, Fernandes L, Olliff C |title=Treatment of polymyalgia rheumatica with intramuscular injections of depot methylprednisolone |journal=Ann. Rheum. Dis. |volume=50 |issue=12 |pages=942–5 |year=1991 |month=December |pmid=1768166 |pmc=1004588 |doi= |url=}}</ref>
* The mainstay of treatment of PMR is low dose [[glucocorticoids]], typically [[prednisone]] or [[prednisolone]].<ref name="pmid23051717">{{cite journal| author=Kermani TA, Warrington KJ| title=Polymyalgia rheumatica. | journal=Lancet | year= 2013 | volume= 381 | issue= 9860 | pages= 63-72 | pmid=23051717 | doi=10.1016/S0140-6736(12)60680-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23051717  }} </ref>
 
Some side effects from the [[steroids]] may occur. Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]]. The doctor should be notified of any signs of sickness.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008  </ref> [[Methylprednisolone]] has better side effect profile with respect to fracture rate and weight gain.<ref name="pmid10948765">{{cite journal |author=Li C, Dasgupta B |title=Corticosteroids in polymyalgia rheumatica--a review of different treatment schedules |journal=Clin. Exp. Rheumatol. |volume=18 |issue=4 Suppl 20 |pages=S56–7 |year=2000 |pmid=10948765 |doi= |url=}}</ref> Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started along with [[steroid]] therapy.
 
Along with medical treatment, patients can increase their chances of recovery by exercising and eating healthy foods. [[Exercise]] will help strengthen the weak [[muscles]], and help to prevent weight gain. A healthy diet will help to keep a strong [[immune system]], and also help build strong muscles and bones.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008  </ref>


Treatment lasts as long as needed; however, it normally takes patients several years to get off of the [[steroids]]. The symptoms may come back when the dosage is lowered.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/page2.htm#6whatis Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref>
* The symptoms resolution begins within a few days after the initiation of the treatment, and this improvement of the symptoms reinforces the diagnosis of PMR.<ref name="pmid23051717">{{cite journal| author=Kermani TA, Warrington KJ| title=Polymyalgia rheumatica. | journal=Lancet | year= 2013 | volume= 381 | issue= 9860 | pages= 63-72 | pmid=23051717 | doi=10.1016/S0140-6736(12)60680-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23051717  }} </ref>


=== Acute Pharmacotherapies ===
* During the treatment, the subject's response to treatment should be monitored through clinical symptoms and measurement of [[ESR]] or [[CRP]].
* [[NSAID]]s helpful in mild disease
* [[Glucocorticoids]] if no response to [[non-steriod anti inflammatory drug]]s ([[NSAID]]s)
*:* [[Prednisone]] 5-20 mg every day--rapid improvement in symptoms
*:* Start taper after symptoms remit and ESR returns to normal (2-4 weeks)
*:* Gradual dose reduction (eg, by 2.5 mg) q 1-4 weeks until dose = 5-10 mg every day
*:* Even ''slower'' taper once dose < 5-10 mg (reduce dose by 1 mg q month)
* Monitor for relapse--occurs in 25-50%, usually because taper too rapid
* Careful observation for signs of [[arteritis]]


=== Other therapies ===
* Treatment lasts as long as needed; however, it normally takes patients several years to get off of the [[steroids]]. The symptoms may come back when the dosage is lowered. The average duration of the treatment with [[glucocorticoids]] is 1 to 2 years; nevertheless, longer [[corticosteroids]] regimens might be necessary among patients who experience relapse of the symptoms.
[[Glucocorticoids]] are the most effective medication for [[polymyalgia rheumatica]]. Other medications are considered in [[steroid]] resistant cases i.e no good response with 20mg/day [[prednisone]], atypical cases and in patients at high risk for [[steroid]] related toxicity.


*[[Methotrexate]] is the commonly used steroid sparing agent.[[Prednisone]] plus [[methotrexate]] treatment is associated with shorter [[prednisone]] treatment.<ref name="pmid15466766">{{cite journal |author=Caporali R, Cimmino MA, Ferraccioli G, ''et al.'' |title=Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=7 |pages=493–500 |year=2004 |month=October |pmid=15466766 |doi= |url=}}</ref>
* Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]].
* Prophylaxis for [[osteoporosis]] with [[calcium]] and [[vitamin D]] should be started along with [[steroid]] therapy.
* [[Infliximab]] use in [[PMR]] has not been proved beneficial and it may be harmful.<ref name="pmid17470831">{{cite journal |author=Salvarani C, Macchioni P, Manzini C, ''et al.'' |title=Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=9 |pages=631–9 |year=2007 |month=May |pmid=17470831 |doi= |url=}}</ref>


*[[Infliximab]] use in [[[PMR]] has not been proved beneficial and it may be harmful.<ref name="pmid17470831">{{cite journal |author=Salvarani C, Macchioni P, Manzini C, ''et al.'' |title=Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=9 |pages=631–9 |year=2007 |month=May |pmid=17470831 |doi= |url=}}</ref>
=== Polymyalgia rheumatica ===
 
* '''1 Glucocorticoids'''
*[[Etanercept]] may be safe and useful in relapsing [[PMR]]. It is modestly effective in [[PMR]] associated with [[giantcell arteritis]] than in isolated [[PMR]].Trials are still in progress to determine the benefit and the differences in response.
** Preferred regimen (1): [[Prednisone]] 12.5-15 mg PO qd for 2-4 weeks (maximum 40 mg/d) then taper it by decreasing the dose by 2.5 mg every 2 to 4 weeks till reaches 10 mg, then decrease the dose by 1 mg every month
 
* '''2 Glucocorticoid-sparing therapies'''
[[EULAR]] response criteria for [[PMR]] comprise a set of core markers for monitoring therapeutic response which include :
** Alternative regimen (1): [[Methotrexate]] 10 mg PO every week<ref name="pmid15466766">{{cite journal |author=Caporali R, Cimmino MA, Ferraccioli G, ''et al.'' |title=Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=7 |pages=493–500 |year=2004 |month=October |pmid=15466766 |doi= |url=}}</ref>
 
** Alternative regimen (2): [[Etanercept]] 25 mg SC twice weekly
*[[ESR]]
 
*[[CRP]]
 
*Visual analogue scale of patient's pain
 
*[[Physician's global assessment]]
 
*[[Morning stiffness]]
 
*Ability to elevate the [[upper limbs]].
 
A disease activity score <7 indicates low activity, 7-17 suggest medium disease activity, >17 indicates high disease activity.<ref name="pmid16823992">{{cite journal |author=Nothnagl T, Leeb BF |title=Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica |journal=Drugs Aging |volume=23 |issue=5 |pages=391–402 |year=2006 |pmid=16823992 |doi= |url=}}</ref>


==References==
==References==
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{{reflist|2}}
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{{WS}}
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Latest revision as of 23:47, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The mainstay of treatment of polymyalgia rheumatica (PMR) is low dose glucocorticoids, typically prednisone or prednisolone. The starting dose of the glucocorticoid treatment is 12.5-15 mg daily for 2 to 4 weeks after which the treatment should be slowly tapered. The average duration of the treatment with glucocorticoids is 1 to 2 years; nevertheless, longer corticosteroids regimens might be necessary among patients who experience relapse of the symptoms. Prophylaxis for osteoporosis with calcium and vitamin D should be started with the steroid therapy.

Medical Therapy

  • The symptoms resolution begins within a few days after the initiation of the treatment, and this improvement of the symptoms reinforces the diagnosis of PMR.[1]
  • During the treatment, the subject's response to treatment should be monitored through clinical symptoms and measurement of ESR or CRP.
  • Treatment lasts as long as needed; however, it normally takes patients several years to get off of the steroids. The symptoms may come back when the dosage is lowered. The average duration of the treatment with glucocorticoids is 1 to 2 years; nevertheless, longer corticosteroids regimens might be necessary among patients who experience relapse of the symptoms.

Polymyalgia rheumatica

  • 1 Glucocorticoids
    • Preferred regimen (1): Prednisone 12.5-15 mg PO qd for 2-4 weeks (maximum 40 mg/d) then taper it by decreasing the dose by 2.5 mg every 2 to 4 weeks till reaches 10 mg, then decrease the dose by 1 mg every month
  • 2 Glucocorticoid-sparing therapies

References

  1. ↑ 1.0 1.1 Kermani TA, Warrington KJ (2013). "Polymyalgia rheumatica". Lancet. 381 (9860): 63–72. doi:10.1016/S0140-6736(12)60680-1. PMID 23051717.
  2. ↑ Salvarani C, Macchioni P, Manzini C; et al. (2007). "Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial". Ann. Intern. Med. 146 (9): 631–9. PMID 17470831. Unknown parameter |month= ignored (help)
  3. ↑ Caporali R, Cimmino MA, Ferraccioli G; et al. (2004). "Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial". Ann. Intern. Med. 141 (7): 493–500. PMID 15466766. Unknown parameter |month= ignored (help)
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