Steroids are the best option for patients with polymyalgia rheumatica.
INTRODUCTION
Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the muscles, usually around the upper arms, shoulders, neck and hips or thighs. The stiffness is worse in the mornings and can severely limit movement and activities. The cause of polymyalgia rheumatic is not known, but it is a fairly common condition that develops most commonly in people aged 60–70 years, and more often in women than men. The condition is usually treated with painkillers or steroid medicines. Recommendations give advice to doctors and patients about the best way to treat and manage particular diseases. They are written by a group of experts based on the most-up to date evidence.
WHY ARE RECOMMENDATIONS NEEDED?
Until now there has been wide variation in how people with polymyalgia rheumatica have been treated. These recommendations aim to help to standardise the care that people receive and support doctors in making decisions.
HOW WERE THE RECOMMENDATIONS DEVELOPED?
Two well-respected societies – EULAR (European League Against Rheumatism) and ACR (American College of Rheumatology) – worked together to develop these recommendations. The authors performed a search of all the literature published on polymyalgia rheumatica and then used a pre-defined methodology to develop each individual point to say whether they were in favour of or against a particular medicine or intervention that might be offered to a patient.
WHAT ARE THE MAIN RECOMMENDATIONS?
The recommendations are listed below. Overall, the recommendations say that it is important to assess each patient holistically, looking at their demographics, disease severity, co-morbidities and risk factors for side effects from steroids, as well as taking into account patient preference and choice. The authors emphasise that it is important to make sure that the diagnosis of polymyalgia rheumatica is confirmed properly before beginning to use steroids, starting with low doses of up to 25 mg. Steroids can cause side effects such as diabetes and osteoporosis (bone loss and fractures) so it is important not to take higher doses than are needed. Patients should receive education on their condition and be given specific exercises to do as well as access to a helpline where they can get advice. Anti-inflammatory painkillers should not be used. Instead, a single daily dose of steroids should be given. Early use of medicines such as methotrexate may be recommended for people with very severe disease, or those who get no response from steroids or cannot use them. Biologic medicines are not recommended in polymyalgia rheumatica.
Recommendations
1. Use steroids rather than anti-inflammatory painkillers, except where short-term pain relief is needed for other conditions
2. Use the lowest possible dose of steroid
3. Higher doses of steroid may be used as needed in patients with high risk of recurring disease and a low risk of side effects from the steroids
4. The dose of steroid should be reduced once symptoms are better and patients monitored
5. Steroid injections can be considered instead of oral steroids where needed
6. Daily oral steroids should be given in a single dose
7. Methotrexate may be considered in severe disease or for patients who get no response from steroids or cannot use them
8. Biologic medicines such as TNF-inhibitors should not be used
9. An exercise programme may help to maintain muscle mass and function
10. Chinese herbal preparations should not be used
ARE THESE RECOMMENDATIONS NEW?
In 2010 the British Society of Rheumatology (BSR) published recommendations on polymyalgia rheumatica. But this is the first time that EULAR and the ACR have worked together to give a recommendation on management of any rheumatic disease (previous joint projects have looked mainly at disease criteria). These recommendations use new evidence to build on the earlier BSR ones.
HOW RELIABLE ARE THE RECOMMENDATIONS?
The most important limitation of this project is the lack of good trials in polymyalgia rheumatica. It is also possible that the methodology used to write the recommendations is not suitable for assessing very rare outcomes and events.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
These recommendations will be used by doctors to tailor treatments for their patients and help to achieve the best possible outcomes from care. The recommendations are only advice, and they may be adapted by different countries according to how local healthcare systems are set up. The authors would like to see polymyalgia rheumatica given the same standard of care as rheumatoid arthritis. More studies are being planned to investigate polymyalgia rheumatica, and these recommendations will be updated in about 3 years based on any new evidence that has emerged.
WHAT DOES THIS MEAN FOR ME?
These recommendations should ensure better treatment for patients with polymyalgia rheumatica. A more cautious use of steroids and better monitoring and assessment should help to reduce any side effects. If you are taking painkillers for your polymyalgia rheumatic, you may wish to talk to your doctor about alternative treatments that might help you.
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Date summary prepared: October 2015
From: Dejaco, C. et al. 2015 Recommendations for the management of polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2015;74:1799–1807. doi:10.1136/annrheumdis-2015-207492
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