Treatment of polymyalgia rheumatica

Introduction: Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disease in the elderly and is a common indication for long-term steroid therapy. We now know that there is a significant overlap with large-vessel vasculitis and inflammatory arthritis and that the polymyalgic syndrome can herald the onset of various inflammatory illnesses in the elderly. The management of PMR is challenging due to heterogeneity in presentation and response to steroids. Areas covered: This article reviews current treatment options for PMR, strategies for early identification and treatment of relapse, monitoring of disease activity, complications and prevention of adverse effects. Although steroids suppress signs and symptoms of PMR, they are unable to prevent multiple flares and long-term adverse events. The authors review the unmet need for safer and more efficacious treatment of PMR. Expert opinion: Slow tapering following a low initial prednisone dose results in better outcomes than high starting doses and a quick tapering regimen. Leflunomide and tocilizumab are two promising agents and larger studies are needed to confirm their efficacy in resistant PMR. We propose that improved methods for classification (such as the EULAR-ACR classification criteria) and disease assessment together with standardized treatment approaches will serve to improve the care of PMR patients.