So what does one do while waiting for more definitive solutions? I do not routinely add second-line agents in my new patients with GCA and PMR, but I am aggressive in trying to minimize adverse effects of GCCs. I add prophylactic bisphosphonates, follow bone-density scans, vaccinate, and treat hyperlipidemia, hypertension, and hyperglycemia.
Despite conflicting evidence on efficacy, I have occasionally added methotrexate in some of my patients on long-term steroids who have intolerable adverse effects from GCCs. I’ve sometimes been successful in subsequently tapering GCCs.
Lastly, I vigorously pursue other possible—and common—causes of confounding musculoskeletal pain that patients may find responsive to GCCs, but can be treated safely in other ways, such as rotator cuff inflammation or tears, cervical disc disease, and myofascial pain—what I call pseudo-polymyalgia. Treating these might allow steroid tapering in otherwise resistant disease.
References:
- Jover JA, Hernandez-Garcia C, Morado IC, et al. Combined treatment of giant cell arteritis with methotrexate and prednisone; a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2001;134:106-114.
- International Network for the Study of Systemic Vasculitides. A multi-center, randomized, double-blind, placebo-controlled trial of adjuvant methotrexate treatment for giant cell arteritis. Arthritis Rheum. 2002;46:1309-1318.
- Cantini F, Niccoli L, Salvarani C, et al. Treatment of long-standing active giant-cell arteritis with infliximab: report of 4 cases. Arthritis Rheum. 2001;44:2933-2935.
- Salvarani C, Cantini F, Niccoli L, et al. Treatment of refractory polymyalgia rheumatica with infliximab: a pilot study. J Rheumatol. 2003 10(4):760-763.
