musculoskeletal and connective tissue disorders
Polymyalgia Rheumatica
Treatment of Polymyalgia Rheumatica
Prednisone started at 15 to 20 mg orally once a day results in dramatic improvement, often very rapid (in hours or days), and this response can help support the diagnosis. If giant cell arteritis is suspected, the dose of corticosteroids should be higher, and Diagnosis should be done. Treatment effectiveness is monitored by symptoms, ESR, and C-reactive protein. As symptoms subside, corticosteroids are tapered to the lowest clinically effective dose, regardless of ESR. C-reactive protein is more helpful than ESR in guiding response to treatment because ESR may be persistently elevated in older patients because of other reasons. Some patients are able to stop corticosteroids in about 2 years, even sooner without relapse, whereas others require small doses for years. Nonsteroidal anti-inflammatory drugs (NSAIDs) are rarely sufficient. Some patients who are unable to have theirprednisonedose tapered and who have frequent recurrences may benefit from the addition ofmethotrexate(10 to 15 mg orally once a week), if renal function is normal. Adding a second drug in polymyalgia rheumatica is controversial because controlled randomized trials have shown minimal or no benefit. Trials using anti-tumor necrosis factor (TNF) drugs (infliximabandadalimumab) andrituximabhave not shown benefit. In older patients, physicians should watch for and treat complications of corticosteroid use (eg, diabetes, hypertension). Patients takingprednisonelong term should be given a bisphosphonate to prevent osteoporosis. Giant Cell Arteritis may develop at the onset of polymyalgia rheumatica or much later, sometimes even after patients appear cured of the disorder. Therefore, all patients should be instructed to immediately report headache, muscle pain during chewing, and, particularly, visual disturbances to their physician. 