Corticosteroid Use in Acute Polymyalgia Rheumatica Should be Reassessed

Dr. Brawer

When I started my rheumatology practice 40 years ago, it quickly became apparent that many referrals of presumed polymyalgia rheumatica (PMR) patients and presumed giant cell arteritis (GCA) patients were the recipients of devastating side effects from long-term corticosteroid (CS) use that could not be discontinued due to prompt recurrence of inflammatory phenomena. It was at that point in time that I began to take a critical look at patient education and patient preferences in such conditions as PMR and GCA.

As rheumatologists, we are expected to render cost-effective, evidence-based care that will alleviate misery, not cause it. Are we so hypocritical that we can criticize a colleague on Monday for having subjected a patient to the ravages of chronic CS use, and then reverse course on Tuesday by prescribing identical treatment for another patient in order to expedite care on a hectic day? Patients need reliable information on CS use to become their own advocates. Indeed, routine CS use in acute PMR is a conversation that is in need of reassessment.

Prospective Study

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I recently completed the only prospective study ever published on the natural course of acute PMR without the use of CS, and the results are in stark contrast to two recent publications outlining classification and treatment recommendations in PMR.^1-3

Observing the clinical course of 95 consecutive patients with acute PMR over an average four-year follow-up, the data revealed that most patients (77%) evolved into seronegative rheumatoid arthritis (RA), and true PMR was infrequent in the absence of biopsy-proved GCA. Only 13% of subjects stayed true to form with their PMR presentation and did not evolve into another specific definitive diagnostic category.

Regarding therapy, I found that 85% of the RA patients treated with hydroxychloroquine (HCQ) were dramatically responsive to this medication (the remainder of the RA patients were subsequently treated with other disease-modifying anti-rheumatic drugs [DMARDs]) and continued to remain free of CS use. In addition, none of the true PMR patients and none of the biopsy-proved GCA patients had any response to HCQ treatment. Interestingly, fever, night sweats and weight loss were not discriminating features and were equally distributed among the RA, PMR and GCA patients.

To me, these findings suggest that for most patients with PMR, with the combined use of non-steroidal anti-inflammatory drugs and HCQ (or other DMARDs as needed), one could avoid the use of CS in the vast majority of patients.

The Path Forward

If confirmed by other future prospective protocols, this methodology offers a clear and rational alternative to current published treatment recommendations in PMR.

Arthur E. Brawer, MD, has been the director of rheumatology at Monmouth Medical Center in Long Branch, N.J., for the past 40 years. He is an associate clinical professor of medicine at Drexel University School of Medicine in Philadelphia. His published research interests encompass new arthritis syndromes, new arthritis treatments, physical trauma and arthritis, alternative and complementary medicine, adverse environmental exposure, vaccination-induced ailments and silicone breast implants. He has testified before Congress, the Food and Drug Administration, the Department of Health and Human Services, the Office of Women’s Health at the White House, and the United Nations. Dr. Brawer continues to maintain a solo rheumatology practice and continues to actively teach students and residents.

References

1. Dasgupta R, Cimmino MA, et al. 2012 provisional classification criteria for polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum. 2012 Apr;64(4):943–954.
2. Dejaco C, Singh YP, et al. 2015 recommendations for the management of polymyalgia rheumatica. Arthritis Rheum. 2015 Oct;67(10):2569–2580.
3. Brawer AE. Polymyalgia rheumatica: Observations of disease evolution without corticosteroid treatment. Open Access Rheumatol. 2016 Apr 1;2016-8:45–49.