Polymyalgia Rheumatica Clinical Practice Guidelines (SIR, 2020)

Italian Society of Rheumatology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 11, 2020

In April 2020, the Italian Society of Rheumatology published their recommendations for the management of patients with a diagnosis of polymyalgia rheumatica.[1]

Pretreatment Evaluation

All patients with clinically diagnosed polymyalgia rheumatica (PMR) should be assessed for similar or associated conditions, particularly inflammatory disorders such as giant cell arteritis and rheumatoid arthritis.

Patients should also be assessed for comorbidities, such as the following conditions, that can affect the management of PMR: hypertension, diabetes, glucose intolerance, cardiovascular disease, dyslipidemia, peptic ulcer, and osteoporosis (particularly a history of recent fractures); cataracts and glaucoma; chronic or recurrent infections; concurrent therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and other medications; and risk factors for steroid-related adverse effects.

Female sex, an elevated erythrocyte sedimentation rate, and peripheral inflammatory arthritis may be risk factors for relapse and/or prolonged therapy.

Laboratory and Imaging Studies

Before treatment is started, the following laboratory studies should be ordered: C-reactive protein level and/or erythrocyte sedimentation rate, tests for rheumatoid factor and anti-cyclic citrullinated peptide antibodies, complete blood cell count, measurement of glucose and creatinine levels, liver function tests, a bone profile (including calcium and alkaline phosphatase levels), and urinalysis. Protein electrophoresis and measurement of thyroid-stimulating hormone and creatine kinase levels may also be helpful.

Chest radiography and abdominal ultrasound may be useful in ruling out other conditions in the differential, and bone densitometry may have a role in monitoring treatment.

Consultations

Consider consulting a specialist if the patient has an atypical presentation (eg, peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, or age <60 years); experiences or is at high risk for adverse effects of therapy; has PMR that resists glucocorticoids; experiences relapses; or requires a prolonged course of treatment.

First-line Therapy

Oral glucocorticoids are recommended as first-line therapy and should be started as soon as PMR is diagnosed. A short-term course of an NSAID or another analgesic may be considered for patients who have pain associated with other conditions.

Individualize glucocorticoid therapy and dose-tapering schedules. Start with 12.5-25 mg/day of prednisone or the equivalent. Consider a lower dosage for patients at risk for steroid-related adverse effects and a higher dosage for those who have an increased risk of relapse; however, initial dosages of ≤7.5 mg/day and dosages of >30 mg/day are not recommended.

The target dosage for the initial tapering regimen is 10 mg/day of prednisone or the equivalent within 4-8 weeks. If relapse occurs, increase to the pre-relapse dosage and decrease gradually (within 4-8 weeks) to the dosage at which the relapse occurred. Once remission of PMR is achieved, taper the dosage by 1 mg every 4 weeks (or by 1.25-mg decrements using schedules such as 10/7.5 mg on alternate days) until treatment is discontinued.

Second-line Therapy

Consider the early addition of oral methotrexate (7.5-10 mg/week) to the glucocorticoid regimen in patients at high risk for relapse, prolonged therapy, and/or steroid-related adverse events.

Tumor necrosis factor inhibitors are not recommended for the treatment of PMR.

Nonpharmacologic Management

An exercise program may help maintain muscular mass and function and reduce the risk of falls, particularly in frail patients with PMR and in older patients who are receiving long-term glucocorticoid therapy.

Follow-up

Follow-up visits should be scheduled every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as needed in the event of relapse or as glucocorticoid therapy is tapered and discontinued.

For more information, please go to Polymyalgia Rheumatica.

For more Clinical Practice Guidelines, please go to Guidelines.

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