Steroid-sparing agents in polymyalgia rheumatica: how will they fit into the treatment paradigm?

ABSTRACT

Introduction

Polymyalgia rheumatica is a common inflammatory rheumatic disease in subjects aged 50 years or older and classically presents with shoulder and/or pelvic girdle pain and prolonged morning stiffness. Glucocorticoids represent the standard of treatment; glucocorticoid therapy is usually required for 1–2 years and often results in significant glucocorticoid-related side effects, especially in the elderly.

Areas covered

In this review, we aimed to provide a comprehensive overview of the management of polymyalgia rheumatica, with a particular focus on adjunctive therapies to the standard glucocorticoid treatment.

Expert opinion

Given the high frequency of disease relapses (one-third of patients) and the adverse events related to prolonged glucocorticoid use, the need for glucocorticoid-sparing agents remains an important issue in the management of polymyalgia rheumatica. In selected patients, who are at risk for glucocorticoid-related side effects or in those with glucocorticoid-refractory disease, the addition of a glucocorticoid-sparing agent, either a synthetic or biologic disease-modifying anti-rheumatic drug, may represent a reasonable and effective therapeutic approach.

KEYWORDS:

• DMARDs
• glucocorticoids
• methotrexate
• polymyalgia rheumatica
• tocilizumab

Article highlights

• Polymyalgia rheumatica is one of the most common inflammatory rheumatic disorders among the elderly, and it is characterized by shoulder, neck, and pelvic girdle pain and stiffness.

• Treatment still relies on long-term GC therapy and, especially in resistant patients, is associated with severe adverse events.

• The role of methotrexate is still debated; however, it may be used as the first choice DMARD in relapsing disease.

• IL-6 inhibitors are the most promising steroid-sparing agents, even from disease onset.

• Less toxic formulations of GCs (e.g. selective GC-receptor modulators or liposomal forms) are being studied to minimize adverse events.

Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.