Polymyalgia rheumatica (PMR) responds well to glucocorticoids such as prednisone when given in small to medium-sized doses. But because the condition tends to persist for months or even years, adverse effects develop in most patients (Gabriel, et al. Arthritis Rheum 1997;40:1873). A variety of steroid sparing drugs have been tried. One NSAID, Tenidap, showed steroid sparing efficacy but also relatively frequent adverse effects. The new Cox-2 inhibitor drugs have not been studied adequately in PMR to determine if they have a role in certain cases.
Experience with cytotoxic drugs has been mainly in cases of giant cell arteritis (GCA), some of whom also had PMR. Even in GCA, cytotoxic investigations have been limited. Because of the close link between GCA and PMR it would be presumed that drugs useful for GCA would also be effective in PMR. Methotrexate has been studied most. Two recent randomised, double-blind, placebo-controlled studies using methotrexate as a steroid sparing agent are the best work on this question to date, but gave different results. In one (Jover, et al. Ann Intern Med 2001;134:106), 33 patients completed the trial. 18 patients were given prednisone plus placebo, and 15 were given daily prednisone plus 10 mg methotrexate per week. All were followed for 24 months. The group receiving methotrexate with prednisone experienced fewer relapses (p = 0.02) and used significantly less prednisone (p = 0.004) over the study period. The second study (Hoffman, et al. In press) was also a prospective randomised double-blind study. 98 patients were enrolled. 51 received methotrexate (mean dose 15 mg per wk) plus prednisone, and 47 received placebo and prednisone. The results showed that the methotrexate group was not different from the placebo group regarding outcome and prednisone dose. The reasons for the differences between these studies is not completely clear but will be discussed. Thus, at this time there are no steroid sparing drugs that can be relied on for PMR. At this time in the practice setting we would recommend a trial of methotrexate only in patients who at very high risk of developing steroid side effects. Additional investigations with this drug and others is needed.
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