Corticosteroid Use in Acute Polymyalgia Rheumatica Should be Reassessed

Dr. Brawer

When I started my rheumatology practice 40 years ago, it quickly became apparent that many referrals of presumed polymyalgia rheumatica (PMR) patients and presumed giant cell arteritis (GCA) patients were the recipients of devastating side effects from long-term corticosteroid (CS) use that could not be discontinued due to prompt recurrence of inflammatory phenomena. It was at that point in time that I began to take a critical look at patient education and patient preferences in such conditions as PMR and GCA.

As rheumatologists, we are expected to render cost-effective, evidence-based care that will alleviate misery, not cause it. Are we so hypocritical that we can criticize a colleague on Monday for having subjected a patient to the ravages of chronic CS use, and then reverse course on Tuesday by prescribing identical treatment for another patient in order to expedite care on a hectic day? Patients need reliable information on CS use to become their own advocates. Indeed, routine CS use in acute PMR is a conversation that is in need of reassessment.

Prospective Study

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I recently completed the only prospective study ever published on the natural course of acute PMR without the use of CS, and the results are in stark contrast to two recent publications outlining classification and treatment recommendations in PMR.^1-3

Observing the clinical course of 95 consecutive patients with acute PMR over an average four-year follow-up, the data revealed that most patients (77%) evolved into seronegative rheumatoid arthritis (RA), and true PMR was infrequent in the absence of biopsy-proved GCA. Only 13% of subjects stayed true to form with their PMR presentation and did not evolve into another specific definitive diagnostic category.

Regarding therapy, I found that 85% of the RA patients treated with hydroxychloroquine (HCQ) were dramatically responsive to this medication (the remainder of the RA patients were subsequently treated with other disease-modifying anti-rheumatic drugs [DMARDs]) and continued to remain free of CS use. In addition, none of the true PMR patients and none of the biopsy-proved GCA patients had any response to HCQ treatment. Interestingly, fever, night sweats and weight loss were not discriminating features and were equally distributed among the RA, PMR and GCA patients.

To me, these findings suggest that for most patients with PMR, with the combined use of non-steroidal anti-inflammatory drugs and HCQ (or other DMARDs as needed), one could avoid the use of CS in the vast majority of patients.

The Path Forward

If confirmed by other future prospective protocols, this methodology offers a clear and rational alternative to current published treatment recommendations in PMR.