Background Treatment of Polymyalgia rheumatica (PMR) is subject to wide variations in clinical practice. We are currently developing new management guidelines for PMR for endorsement by ACR and EULAR.
Objectives To review the evidence on the efficacy and safety of therapeutic interventions in PMR patients informing the ACR/EULAR PMR guidelines development group.
Methods We use GRADE methodology as framework for the guidelines development process. For the systematic literature review, we searched MEDLINE, Embase, PubMed, CINAHL, Web of Science and the Cochrane Library (1970 through June 2013) for relevant articles on initial glucocorticoid (GC) doses, length, tapering and administration of glucocorticoid treatment as well as the use of NSAIDs, intramuscular methylprednisolone (i.m. MP), synthetic and biologic disease modifying anti-rheumatic drugs and non-pharmacological interventions. The grey literature including abstracts from international conferences or data from trial registries was reviewed in order to identify additional peer-reviewed articles.
Results Out of 10078 records, we identified 25 articles meeting our inclusion and exclusion criteria. There is moderate QoE from a single study indicating that an initial GC dose of 20mg/day is associated with a lower short-term relapse rate than 10mg/day but at cost of a higher rate of adverse events (AE) (1 study, very low QoE). Rapid tapering of GC was also associated with a higher relapse rate (low QoE, 1 study). Very low quality of evidence (QoE) indicated that the use of NSAIDs is associated with a lower rate of vertebral fractures but also with a higher rate of infections, cardiovascular events and hypertension. Moderate QoE (1 study) indicated a comparable efficacy of i.m. MP and oral GCs. I.m. MP use was associated with a lower cumulative GC dose and less weight gain than oral GCs. Moderate to high QoE from 1-2 studies indicated a benefit of methotrexate (MTX) regarding remission and cumulative GC-dose, whereas data from 1-4 studies (very low QoE) showed no effect. Infliximab (moderate QoE, 1 study) and etanercept (low QoE, 1 study) were ineffective for PMR treatment. Among non-pharmacological interventions added to standard GC therapy, there was very low to moderate QoE (1 study) for an effect of Chinese Yanghe decoction on ESR, GC related AE and morning stiffness. Low QoE suggested a higher response rate by the addition of Biqi capsules to GC therapy.
Conclusions There is moderate to high QoE for a benefit of i.m. MP and MTX use for treatment of PMR. The evidence on initial GC doses and subsequent tapering regimens is limited, and there is no clear evidence that NSAIDs and anti-TNFα agents are effective.
Disclosure of Interest C. Dejaco Grant/research support: Pfizer, MSD, AbbVie, Speakers bureau: Pfizer, MSD, AbbVie, UCB, Roche, BMS, Y. Singh: None declared, P. Perel: None declared, A. Hutchings: None declared, E. Matteson Grant/research support: Novartis, Centocor, genentech, Pfizer, UCB Group, Hoffmann-LaRoche, Schering, B. Dasgupta Consultant for: Merck, Roche, Napp, Mundipharma, Servier