Patients with PMR requiring methotrexate and leflunomide

Which patients with polymyalgia rheumatica (PMR) require treatment with methotrexate and leflunomide?

Bhaskar Dasgupta: If you use 15 mg prednisolone in patients with PMR, about 55% will have a complete response. So these patients will have more than 70% global improvement, morning stiffness for less than half an hour, and normal inflammatory markers when you assess them at 4 weeks. But if patients have an incomplete response, [they will have] less than this, so in about 40% of these patients, I will consider using these disease-modifying antirheumatic drugs (DMARDs) up early.

One important distinction is that if the patient does not have any response to steroids, then we start thinking that we have got the diagnosis wrong, you have to think of something else. That is when we do not start methotrexate but investigate for other conditions. That is when we do early positron emission tomography (PET) scans, PET computed tomography (CT), and other imaging studies for these patients.