Background Glucocorticoids (GCs) are effective for polymyalgia rheumatica (PMR); however, some patients show inadequate responses to initial GC doses or relapses during GC tapering and develop side effects of GCs. The 2015 EULAR/ACR recommendations for the management of PMR has been proposed very recently, in which early introduction of methotrexate (MTX) in addition to GCs was recommended for such GC-resistance or -intolerance1). Similarly, we have used MTX frequently for PMR patients with relapse, prolonged GC therapy and high risk of GC adverse effects.
Objectives To examine the efficacy of this 2015 EULAR/ACR recommendation for managing Japanese patients with difficult-to-treat PMR.
Methods Thirty-five patients were diagnosed with PMR according to the 2012 EULAR/ACR provisional classification criteria for PMR2), including 13 males and 22 females. The average (± SD) age was 69.2 ± 9.4 years; disease duration before therapy 1.9 ± 1.8 months; and the length of observation after starting treatment 23.8 ± 20.7 months.
Results All patients had active PMR, as demonstrated by high serum CRP levels (6.43 ± 4.50 mg/dL), erythrocyte sedimentation rate (ESR; 85 ± 33 mm/hr) and matrix metalloproteinase-3 (MMP-3; 188 ± 132 ng/mL). All patients with newly-diagnosed PMR were treated first with GCs (starting with the mean dose of prednisolone (PSL) of 15 mg/day; rage 10 - 60 mg/day; 60 mg/day for giant cell arteritis). Twenty-two patients experienced disease relapses, when PSL dose was reduced to 7.1 ± 3.7 mg/day at 7.9 ± 5.8 months. MTX (8.8 ± 3.4 mg/wk) was added in 21 patients and PSL was increased in a patient. Seven patients relapsed after MTX introduction, followed by adding tocilizumab (TCZ) in 6 patients and azathioprine in a patient. One patient with tocilizumab was thereafter switched to adalimumab due to insufficient response to TCZ. At present, PMR became inactive and GC was successfully withdrawn in 8 patients after total 18.0 ± 4.7 month treatment. No significant differences in basal levels of CRP, ESR and MMP-3 was found between GC-response and –resistant patients. Adverse effects included cataract (n=2), diabetes (n=1), metabolic syndrome (n=1), and osteoporosis (n=1).
Conclusions The results indicate that early addition of MTX for GC-resistance and –intolerance, as recommended by the EULAR/ACR recommendations, may be effective also for Japanese patients, but there are cases refractory to MTX addition, who will require further treatment options including TCZ.
Dejaco C, et al. Ann Rheum Dis 2015;74:1799–807.
Dasgupta B, et al. Ann Rheum Dis 2012;71:484–92.
Disclosure of Interest None declared