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Am Fam Physician. 2010;81(6):788

Background: Polymyalgia rheumatica is characterized by myalgias and morning stiffness in the shoulder and pelvic girdles and neck, in addition to low-grade fever, fatigue, and weight loss. The syndrome is usually treated with long-term corticosteroids, although other agents have also been used. However, there has been no review of the evidence for current treatments. Hernández-Rodríguez and colleagues analyzed previously published studies to determine the best treatment regimen for patients with polymyalgia rheumatica.

The Study: The authors reviewed English-language medical literature published between 1957 and December 2008 for studies investigating the treatment of polymyalgia rheumatica in 20 or more patients. Treatment regimens, relapse rates, and related adverse effects were analyzed.

Results: Thirty studies involving 2,161 patients with polymyalgia rheumatica were reviewed, including 13 randomized trials and 17 observational studies. No systematic reviews or meta-analyses were found. The type of treatment regimen that was used varied considerably.

Less than 1 percent of patients required prednisone or prednisolone at starting dosages above 15 mg per day to control symptoms. Relapses were more common if the initial dosage was 10 mg per day, whereas more than 15 mg per day had a greater risk of steroid-related adverse effects without additional benefit. Up to 50 percent of patients were able to discontinue steroid use within two years when the initial prednisone dosage was 10 to 20 mg per day. Fewer relapses occurred when steroid use was tapered slowly (e.g., less than 1 mg per month or 1 mg every two months). Intra-articular methylprednisolone (Depo-Medrol) showed some benefit, but the authors believed it should be reserved for patients at high risk of glucocorticoid-related adverse effects or when polymyalgia rheumatica was limited to the shoulder girdle.

Oral and intramuscular methotrexate in a dosage of 10 mg per week had steroid-sparing effects and decreased relapse rates when added to prednisone therapy. Adding infliximab (Remicade) to prednisone showed no benefit in newly diagnosed patients with polymyalgia rheumatica. Azathioprine (Imuran) added to prednisolone modestly reduced the total cumulative steroid dose required, but the results were difficult to evaluate because of the small number of patients using this approach. Nonsteroidal anti-inflammatory drug monotherapy may relieve symptoms in a minority of patients with polymyalgia rheumatica, but showed no benefit over steroid monotherapy, and had a higher risk of adverse effects.

Conclusion: The authors conclude that the current evidence suggests using prednisone or its equivalent at a starting dosage of 15 mg per day to control polymyalgia rheumatica activity in most patients. Slow tapering of steroid use is associated with fewer relapses and overall faster cessation of corticosteroid therapy. Of the steroid-sparing agents that were tested in this study, oral or intramuscular methotrexate added in dosages of at least 10 mg per week to prednisone therapy reduced the overall glucocorticoid requirement.

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