2015 ACR-EULAR guidelines on management of polymyalgia rheumatica

In 2015, the American College of Rheumatology and the European League Against Rheumatism (ACR-EULAR) published new guidelines on the management of polymyalgia rheumatica (PMR). What do they change in clinical practice?

Bhaskar Dasgupta: I think the most important aspect of these guidelines is that if you read the paper, there is a lot of patient representation. We have made these guidelines with help, particularly of the PMRGCAuk (Polymyalgia Rheumatica & Giant Cell Arteritis UK) patient charity in England. So these guidelines reflect the patient-centered point of view.

The most important part of the guidelines is what we call the “overarching principles of care.” We have defined, for example, that in every patient with PMR you need to establish the diagnosis and what comorbidities may be present, like diabetes, hypertension, osteoporotic risk factors, infection-related risk factors. You need to assess the disease severity, depending on the pain, stiffness, disability. Then, after looking at all these aspects and the steroid-related risk factors, use an individualized dose of steroids. What we are saying is that not every patient with PMR requires the same dose of steroids. The basic principle is about 15 mg; some may require lower dose, some may require higher dose, depending on the severity of the disease and presence or absence of other risk factors. So, the overarching principles are very important.

We have made individual recommendations; for example, we say that we strongly recommend against using nonsteroidal anti-inflammatory drugs (NSAIDs). We have talked about an individualized dosing schedule for PMR: basically, get to around 10 mg of prednisolone in about 6 weeks and then go down very gradually, 1 mg daily each month, etc. Everything should be down very gradually, and keep in mind that while you are reducing steroids, you might get relapses, and then you may have to go up on the higher dose or use a disease-modifying agent.

One important recommendation that we have made is “month 1”: you must monitor the patient and get them to your clinic 4 weeks after starting steroids. If the patient has not had a good response to steroids, if the patient has all these other risk factors, comorbidities, consider starting a disease-modifying agent within a month of starting the steroids. At the moment, the only drug where there is some evidence is methotrexate, so we have said methotrexate is recommended, but there are many other new drugs that are coming in to the pipeline. We have done a lot of work with leflunomide, to show that it works in patients with PMR or in giant cell arteritis, so you might consider using that.

We have also made recommendations about biologic agents. We have said that anti-tumor necrosis factor (TNF) agents do not really work in PMR. But we are looking at interleukin-6 blocking agents, like tocilizumab, etc.

We have also made a recommendation on intramuscular steroids, so intramuscular methylprednisolone. There is a rule for using intramuscular methylprednisolone for relapses or mild disease or where there are relative contraindications, where you need a lower mineralocorticoid dose, because intramuscular methylprednisolone gives you a total accumulative dose much lower than oral prednisolone.

These are some of the recommendations that we have made in 2015 EULAR-ACR treatment guidelines.