For Michael Lucke, MD, staff rheumatologist at the Lupus Center for Excellence, West Penn Allegheny Health System in Pittsburgh, the conditional recommendation to use methotrexate early in the management of PMR was surprising. “While often used to treat PMR, the data for methotrexate use [have] been contradictory, and trials have included small numbers of patients,” he says. “Further research on high numbers of patients on different doses of methotrexate will be required to advance methotrexate to a stronger recommendation.”
Saying that the recommendation for the addition of methotrexate was a little vague, Petros Efthimiou, MD, associate chief of rheumatology at New York Methodist Hospital and associate professor of Medicine and Rheumatology at Weill Cornell Medical College in New York City, adds that “the decision to use methotrexate is left to the clinical acumen of the physician for each individual case.”
Dr. Matteson acknowledges that some practitioners will not agree on the potential benefit of methotrexate and says that he recognizes that if or when methotrexate should be used in the course of disease is not yet settled. Others, he says, may not agree that NSAIDs or anti-tumor necrosis factor agents should not be used to manage PMR, despite their poor efficacy as found in the evidence.
Dr. Matteson also stresses that, characteristic of all guidelines, the recommendations offered are just that, recommendations. “As with all guidelines, the individual patient’s situation and needs should always be taken into account,” he adds.
Roadmap for Primary Care Physicians
The recommendations were developed not just to provide guidance to specialists about optimal care of PMR patients, but because “there is a lot of confusion among non-specialists about the proper management of PMR, and access to rheumatologists is not always readily available,” says Dr. Efthimiou. “These recommendations address this unmet need and provide a roadmap for primary care physicians to treat PMR and, hence, avoid delays in treatment.”
Because most patients with PMR are diagnosed and treated in the primary care setting, Dr. Matteson hopes the guidelines will be widely disseminated and adopted by all practitioners.
“Importantly, the guidelines emphasize the need for correct diagnosis and recognize the role of specialty care by rheumatologists in the management of these patients, especially for difficult and unusual cases,” he says.
Also emphasizing that primary care physicians are usually the first physicians to assess PMR in a patient, Dr. Lucke says, “the guidelines can help avoid common pitfalls of starting prednisone at too high a dose, as well as tapering prednisone too rapidly.”
