Polymyalgia rheumatica is a disease characterized by pain and stiffness in the proximal regions of the extremities and the trunk. It tends to occur in middle-aged and elderly persons who often experience pain and stiffness for a month or longer before diagnosis. Standard therapy consists of oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. Because these medications are associated with adverse side effects, Gabriel and colleagues performed a retrospective study to analyze the long-term incidence and risks of adverse events associated with their use in patients diagnosed with polymyalgia rheumatica.
The authors reviewed an extensive database of patients who were part of the Rochester (Minn.) Epidemiology Project and identified all patients diagnosed with polymyalgia rheumatica between 1970 and 1991. Diagnostic criteria included an age of 50 years or older; a sedimentation rate of 40 mm per hour or more; and bilateral pain and morning stiffness for at least one month involving two of the following areas: neck or torso, shoulders or proximal regions of the arms. When the diagnosis was questionable, three rheumatologists independently reviewed the patient's medical data and reached a consensus. A total of 232 patients were included in the study. Patients were then categorized into three groups: those treated with corticosteroids alone, those treated with NSAIDs alone and those treated with both. Data on adverse events often associated with steroid or NSAID use were collected. These events included diabetes mellitus, symptomatic vertebral fractures, hip fractures, femoral neck fractures, wrist fractures, avascular necrosis, bacteremia or sepsis, upper gastrointestinal bleeding, pneumonitis, cataracts, hypertension and myopathy. Follow-up for all patients continued until death, relocation or January 1, 1992.
The mean age at diagnosis of polymyalgia rheumatica was 72.9 years, and the average follow-up time was eight years. Among the 175 patients treated with corticosteroids (with and without NSAIDs), the mean duration of therapy was 2.4 years, and the average daily dosage was 9.6 mg. A total of 282 adverse events were recorded after polymyalgia rheumatica was diagnosed in 160 of the 232 patients. Patients who received corticosteroid therapy with NSAIDs were more likely to experience adverse events. Sixty-seven percent of patients treated only with NSAIDs and 65 percent of patients treated with only a corticosteroid had at least one adverse event. The average time from initiation of therapy to the first adverse event was 1.6 years for all patients who had adverse events. The most common events included cataracts, infections, hypertension and vertebral fractures. The risks of diabetes, vertebral fracture, femoral neck fracture and hip fracture were two to five times greater in patients with polymyalgia rheumatica than in age- and sex-matched control subjects from the same population. Patients who did not receive medical care or consultation from a rheumatologist received an average initial daily dosage of prednisone that was 9.5 mg higher than the dosage in patients who did have a rheumatologist involved in their medical care. The three variables found to independently increase the risk of an adverse event were female sex, older age at diagnosis and a cumulative dose of prednisone in excess of 1,800 mg.
The authors conclude that although the duration of treatment for polymyalgia rheumatica is often short and the dosages of corticosteroids and NSAIDs used to treat this condition are low, there is a high incidence of adverse events, and they are associated with significant morbidity. Physicians should be vigilant about maintaining patients with polymyalgia rheumatica on the lowest dosage of medication for the shortest period of time that is clinically necessary.
editor's note: Although this is a retrospective study, its results still point out the risks of treating elderly patients with long-term corticosteroids. The decision to initiate corticosteroid therapy may be especially difficult in a patient with a condition such as polymyalgia rheumatica—a disease that must be diagnosed clinically and whose etiology remains unknown. A rapid response to corticosteroid therapy is usually the rule in patients with polymyalgia rheumatica, and this can aid the clinician in confirming the diagnosis. Consultation with a rheumatologist is quite reasonable if the diagnosis is uncertain. These patients must then be carefully monitored for the occurrence of the adverse events noted in the study. Preventive measures, which include the addition of calcium, estrogen or bisphosphonate therapy, should be considered in all of these patients.—j.t.k.