What’s New in Polymyalgia Rheumatica?

EULAR 2024 (VIENNA)—What’s new in polymyalgia rheumatica (PMR)? That’s the question Frank Buttgereit, MD, senior consultant and deputy head of the Department of Rheumatology and Clinical Immunology, University Medicine, Berlin, set out to answer at EULAR 2024. Harry Spiera, MD, is credited with describing the first American case series of PMR in the 1970s.¹ Since then, we have come to recognize PMR as the most common inflammatory disease in people aged 50 and older.² In this WIN session, Dr. Buttgereit summarized the latest advances in the diagnosis and treatment of PMR.

Assessing Patients

When screening a patient for PMR, Dr. Buttgereit said rheumatologists should also screen for giant cell arteritis (GCA), a frequently overlapping condition whose co-occurrence has implications for patient management. Subclinical GCA in PMR—based on imaging or biopsy—has a pooled prevalence of about 23%, yet the clinical implications of these findings are unclear.³

In a study conducted by De Miguel et al., 150 patients with PMR and without clinical symptoms of GCA were stratified into two groups: 1) those with isolated PMR and 2) those with subclinical GCA, based on ultrasound imaging. These groups were followed for two years. The study found patients with PMR and subclinical GCA have a fourfold higher rate of relapse than patients with isolated PMR. Additionally, they found a lower starting dose and rapid taper of glucocorticoids in the first three months of treatment increases the risk of relapse in these patients.⁴

These findings raise the question: Should all patients with PMR have a vascular ultrasound assessment? Dr. Buttgereit believes that such an evaluation should be considered at the time of diagnosis, particularly if clinician sonographers are accessible.

Treatment

Dr. Buttgereit noted that the 2015 Recommendations for the Management of PMR, jointly published by EULAR and the ACR, remains a helpful guideline for practicing rheumatologists.⁶ This guideline recommends clinicians begin treatment with prednisone in a dose ranging from 12.5–25 mg daily. For patients with a high risk or relapse and low risk of adverse events, the dose can be up to 30 mg of prednisone daily. Conversely, doses as low as 7.5 mg of prednisone daily can be prescribed for patients with comorbidities (i.e., diabetes, osteoporosis or glaucoma).^5,6

The initial tapering of glucocorticoids should allow the patient to reach a dose of 10 mg of prednisone daily four to eight weeks after therapy is initiated. Subsequent tapering should be in increments of 1 mg every four weeks.^5,6