Drug therapies for polymyalgia rheumatica: a pharmacotherapeutic update

ABSTRACT

Introduction: Polymyalgia rheumatica (PMR), a common disease in individuals older than 50 in the western world, is characterized by bilateral inflammatory pain involving the shoulder girdle and less commonly the neck and pelvic girdle. The main goals of the currently available treatment are to induce remission and prevent relapse.

Areas covered: This review briefly presents the main epidemiological and clinical features of PMR and discusses in depth both its classical management as well as new therapies used in PMR.

Expert opinion: In general, patients with isolated PMR experience a rapid response (in less than seven days) to 12.5–25 mg/prednisone/day. Methotrexate is the conventional disease-modifying antirheumatic drug most commonly used for disease management, especially for relapses of the disease. However, this agent often yields a modest effect. Randomized controlled trials do not support the use of antitumor necrosis factor agents in PMR. Several case series and retrospective studies have highlighted the efficacy of the anti-interleukin-6 receptor antibody tocilizumab in PMR. However, controlled trials are needed to fully establish the efficacy of this biologic agent in PMR. The potential beneficial effect of the Janus-kinase inhibitors remains to be determined.

KEYWORDS:

• Anti-interleukin-6 receptor tocilizumab
• antitumor necrosis factor agents
• giant cell arteritis relapses
• methotrexate
• polymyalgia rheumatica
• prednisone

Declaration of interest

MA Gonzalez-Gay has served on the advisory boards of Roche and Sanofi. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Article highlights

• Polymyalgia rheumatica (PMR) is a common inflammatory disease in individuals older than 50 years from Western countries characterized by severe pain and morning stiffness involving the shoulders, proximal aspects of the arms, the neck, the pelvic girdle and thighs.

• Around 20% of PMR patients have clinical features of giant cell arteritis (GCA).

• Currently, the diagnosis of PMR is based on the classification criteria proposed by the EULAR and ACR in 2012. The presence of bursitis and/or tendinitis by ultrasound in proximal areas is included in this set of criteria.

• Other imaging techniques, such as the ^18F-FDG PET/CT scan, have shown that at least a third of patients with PMR may have large vessel involvement, even in the absence of the typical cranial manifestations of GCA.

• Glucocorticoids represent the mainstay of the therapy in PMR.

• Conventional immunosuppressive drugs, especially methotrexate (MTX), have been used in relapsing PMR patients. They may yield a glucocorticoid sparing effect.

• In patients with poor response to glucocorticoids and MTX, anti-IL-6 receptor antibody tocilizumab has been used. This biologic agent may be useful in refractory patients in whom large vessel vasculitis is observed by an imaging technique such as PET/CT scan.

• The potential beneficial effect of the Janus-kinase inhibitors in isolated PMR remains to be determined.

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Additional information

Funding

This manuscript was not funded.