Target population: patients diagnosed with PMR based on current diagnostic or classification criteria Key principles of disease management.
A. Determine the diagnosis of PMR and perform an adequate clinical evaluation for differential diagnosis excluding similar diseases (e.g., non-inflammatory diseases, inflammatory diseases such as giant cell arteritis or rheumatoid arthritis, drug-induced, endocrine diseases, infections, tumors).
B. Prior to treatment, all patients with PMR should undergo the following evaluations.
1) Record baseline laboratory data. It is helpful to identify other similar diseases and to retain baseline data to help monitor treatment. Baseline laboratory data include rheumatoid factor and/or anti-citrullinated protein antibodies (ACPA), CRP, and anti-citrullinated protein antibodies.
(ACPA), CRP and/or sedimentation, blood counts, glucose, creatinine, liver function, bone metabolic status (including this, alkaline phosphatase), and urinalysis. Other tests that should be considered include protein electrophoresis, TSH, creatine kinase, and urinalysis.
TSH, creatine kinase, and vitamin D.
2) Based on signs, symptoms, and other diagnostic possibilities, additional serologic tests including ANA, ANCA, or nodal tests should be performed to rule out other diseases when possible. The physician may also consider additional tests such as chest radiographs to rule out other diagnoses.
3) Evaluate for comorbidities especially hypertension, diabetes, abnormal glucose tolerance, cardiovascular disease, dyslipidemia, peptic ulcer, osteoporosis (especially recent fracture), cataract or glaucoma (including risk factors), chronic or recurrent infections, and chronic or recurring infections.
chronic or recurrent infections, coadministration of NSAIDs, other relevant coadministrations, and risk factors associated with adverse effects of glucocorticoids. In low to moderate quality studies, women were found to be at higher risk for glucocorticoid use than men.
risk was higher in women than in men.
(4) The role of risk factors for relapse or prolonged treatment is unclear. Baseline characteristics associated with increased relapse rates and/or treatment prolongation in low to moderate quality studies include: female, high blood sedimentation (>40 mm/h), and peripheral inflammatory arthritis. However, a subset of studies, also of low to moderate quality, did not suggest that the above factors were associated with relapse/prolonged treatment.
C. Specialist referral should be considered, especially in patients with atypical symptoms (e.g., peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age at onset <60 years), patients with treatment-related adverse effects or at high risk, those refractory to glucocorticoids, and/or those with relapse/prolonged treatment cycles.
D. The treatment of PMR should follow the principle of optimal care, and the treatment plan should be decided by the patient and the treating physician.
E. Individualized treatment plan. The initial glucocorticoid treatment dose and subsequent dose reduction plan should fully integrate the patient’s ideas and preferences.
F. Enhance patient education based on the impact of PMR and treatment including comorbidities and disease predictors, and develop individualized exercise plans.
G. All patients undergoing treatment should be evaluated for risk factors and evidence of glucocorticoid-related adverse effects, comorbidities, other relevant treatments, evidence of disease relapse/prolonged treatment, and risk factors. In
Disease and laboratory data should be documented on an ongoing basis when glucocorticosteroids are prescribed. Follow-up visits are recommended every 4-8 weeks in year 1 and every 8-12 weeks starting in year 2; relapse or prednisone dose reduction or discontinuation
The follow-up should be done when relapse or prednisone is reduced or stopped.
H. It is critical for patients to receive quick and direct advice from their physician, nurse, or trained health care provider to report any changes in their condition such as relapses or treatment-related side effects.
Special recommendations for managing patients with PMR.
1. Patients are strongly advised to use glucocorticoids rather than NSAIDs, unless there is other disease-related pain that requires short-term application of NSAIDs and/or analgesics. There is no special recommendation for the use of analgesic drugs.
2. The application of the shortest course of effective glucocorticoid therapy is strongly recommended.
The lowest effective dose of glucocorticosteroid is recommended in some cases, with initial treatment equivalent to prednisone 12.5-25 mg per day.
People with a high risk of relapse and a low risk of adverse effects may choose a high dose within this dose range, while those with associated comorbidities such as diabetes, osteoporosis, glaucoma and other risk factors for glucocorticoid-related adverse effects should choose a lower dose. An initial therapeutic dose of less than 7.5 mg per day is not recommended.
An initial therapeutic dose greater than 30 mg per day is strongly discouraged.
4. It is strongly recommended that individualized dose reductions be made based on the patient’s disease activity, laboratory indicators and adverse effects.
A. Initial dose reduction: reduce the dose to 10mg/d orally within 4-8 weeks.
B. Relapse treatment: Increase the oral prednisone dose to the pre-relapse dose and gradually reduce it to the relapse dose over 4-8 weeks.
C. Once in remission (either initial or relapse treatment), start dose reduction: 1mg/d every 4 weeks (or 1.25mg every other day, e.g. 10mg/7.5mg orally) until remission is maintained.
5. The use of intramuscular methylprednisolone as an alternative to oral glucocorticoids is recommended under certain conditions, and the choice of treatment depends on the choice of the treating physician. In one clinical study, methylprednisolone 120 mg was used as an initial injection every 3 weeks.
Single oral doses of glucocorticoids are recommended over split doses under certain conditions, except when glucocorticoids are reduced to low doses (e.g., <=5 mg prednisone/day) and pain is very pronounced at night.
7. Early addition of methotrexate to glucocorticosteroids is recommended under certain conditions, especially when the risk of relapse is high and/or treatment is prolonged and when risk factors, comorbidities, and/or combined medications exist and glucocorticoid-related adverse
The risk of recurrence and/or prolonged treatment, as well as the presence of risk factors, comorbidities and/or combination of drugs that predispose to glucocorticoid-related adverse effects. Methotrexate should also be added to patients with relapse during follow-up, poor glucocorticoid response, and glucocorticoid-related adverse reactions. The oral dose of methotrexate in clinical trials was
7.5-10mg per week.
8. The application of TNF inhibitors is strongly discouraged.
9. Individualized exercise is recommended for PMR patients under certain conditions to maintain muscle content and function, and to reduce the risk of falls in elderly and frail patients with long-term glucocorticoid application.
10.The use of Chinese medicinal preparations Yanghe system capsules and Palsy capsules is strongly discouraged.