Prednisone dosage for the PR is a major concern. Initial dosages can be 20 mg daily, decreased 50% at 21 weeks. The accumulative dose is dangerous for osteoporosis, weight gain, hypertension and heart disease. Methotrexate at 7.5 mg weekly failed to reduce this accumulative dose though 10 mg did help. Now Etanercept (Enbrel) shows useful promise.
Arthritis Rheum. 2007 Dec 15;57(8):1514-9.
Treatment of refractory polymyalgia rheumatica with etanercept: an open pilot study. Catanoso MG, Macchioni P, Boiardi L, Pipitone N, Salvarani C. abstract
- Included a subgroup that were not able to get their dosage below 7.5-10 mg
- 6 cases – open pilot study
- Etanercept 25 twice weekly for 24 weeks
- “A significant reduction in the cumulative prednisone dose 9 months before versus the 9-month study period was observed (mean +/- SD 1,767 +/- 524 mg versus 730 +/- 182 mg; P = 0.028).”
- “Three patients developed nonsevere side effects: bacterial cystitis in 2 and influenza in 1”
- “These results, which should be confirmed in a controlled study, suggest that etanercept may be a safe and useful corticosteroid-sparing agent in relapsing PMR.”
A related drug, infliximab (Remicade) failed to help and was considered to potentially worsen the situation:
Ann Intern Med. 2007 May 1;146(9):631-9. Comment in: Ann Intern Med. 2007 May 1;146(9):674-6. Ann Intern Med. 2008 Jan 15;148(2):166; author reply 166. Summary for patients in: Ann Intern Med. 2007 May 1;146(9):I20. Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial. Salvarani C, Macchioni P, Manzini C, Paolazzi G, Trotta A, Manganelli P, Cimmino M, Gerli R, Catanoso MG, Boiardi L, Cantini F, Klersy C, Hunder GG.
“Although too small to be definitive, the trial provides evidence that adding infliximab to prednisone for treating newly diagnosed polymyalgia rheumatica is of no benefit and may be harmful. If there is benefit, it is unlikely to be large.”
A previous study with metotrexate using 7.5 mg weekly failed to decrease prednisone needs:
However 10 mg Methotrexate weekly did have some effect:
Ann Intern Med. 2004 Oct 5;141(7):493-500. Comment in: Ann Intern Med. 2004 Oct 5;141(7):568-9. Summary for patients in: Ann Intern Med. 2004 Oct 5;141(7):I12. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Caporali R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, Montecucco C; Systemic Vasculitis Study Group of the Italian Society for Rheumatology abstract
- “Twenty-eight of 32 patients in the methotrexate group and 16 of 30 patients in the placebo group were no longer taking prednisone at 76 weeks (P = 0.003).”
- “Fifteen of 32 patients in the methotrexate group and 22 of 30 patients in the placebo group had at least 1 flare-up by the end of follow-up (P = 0.04). The median prednisone dose was 2.1 g in the methotrexate group and 2.97 g in the placebo group (P = 0.03). The rate and severity of adverse events were similar. “
- “Prednisone plus methotrexate is associated with shorter prednisone treatment and steroid sparing. It may be useful in patients at high risk for steroid-related toxicity.”
Comment – in treatment resistant cases, it looks like the addition of methotrexate10 mg (but not 7.5 mg) is beneficial. It reduces prednisone requirements by 29%. Etanercept reduced it by 59%. However each shot is $200.00 and that would come to over $10,000.00 for the 24 week course. Methotrexate is used in cancer chemotherapy and can cause nerve damage neuropathy. Though etanercept has been helpful in occasional neuropathies: link, it can rarely cause optic neuropathy abstract and a reported case of peripheral neuropathy:link
Infections are risks with both treatments.
Any comments?
I have had recurrent (relapsing) PMR for 20 years with dosage from 35mg Prednisone slowly tapered to zero. For the last 6 plus years I have not been able to get down to zero before having a relapse.(Every 7-9 month). Mayo Clinic rheumatologoists didn’t offer any treatment excerpt Prednisone but my local rheumatologist put me on 10 Methotrexate/ week,then 6 months later increased it to 15 mg /week .This has helped me reduce my Prednisone with one (occurring now) partial relapse to 22mg Prednisone. I am now tapering 1 mg Prednisone / week to try to get to 16 mg before I further reduce Prednisone 1 mg every 2-3 weeks (Depending on leg, lower back and shoulder muscle aching. I have an unusually refractory case of PMR but have a normal Dexascan, Blood sugar, weight, blood pressure and intraocular pressure. Ken
I have had PMR for about a year and it’s extremely painful. I’m 60 and many days have a difficult time walking, bending, sleeping. I have been on prednisone for a year and am going back to my doctor this week to try to find alternatives. If you are reading this and you know of anything that might help me with this, please share the information. I have researched and read a lot of info online and it looks like there is very little hope to really ever feeling normal again.
One concern about longterm prednisone is the osteoporosis. Biphosphonates (actonel, fosamax) are used:
Alendronate 5mg/day works:
J. Rheumatol. 2008 Nov;35(11):2249-54.
Alendronate (fosamax)protects premenopausal women from bone loss and fracture associated with high-dose glucocorticoid therapy.
Okada Y, Nawata M, Nakayamada S, Saito K, Tanaka Y.
abstract here:
http://www.ncbi.nlm.nih.gov/pubmed/19031508?dopt=Abstract
(Risedronate) Actonel 2.5 mg/day works too:
Yakugaku Zasshi. 2007 Sep;127(9):1491-6.
Comparative studies on effect of risedronate and alfacalcidol against
glucocorticoid-induced osteoporosis in rheumatoid arthritic patients.
Yamada S, Takagi H, Tsuchiya H, Nakajima T, Ochiai H, Ichimura A, Iwata H, Toriyama T.
abstract here:
http://www.ncbi.nlm.nih.gov/pubmed/17827929?dopt=Abstract
article here:
http://www.jstage.jst.go.jp/article/yakushi/127/9/1491/_pdf
IV pamidronate works well:
Primary Prevention of Glucocorticoid-Induced Osteoporosis with Intermittent Intravenous Pamidronate: A Randomized Trial
Journal Calcified Tissue International
Issue Volume 61, Number 4 / October, 1997
Primary Prevention of Glucocorticoid-Induced Osteoporosis with Intermittent Intravenous Pamidronate: A Randomized Trial
Y. Boutsen1, J. Jamart2, W. Esselinckx1, M. Stoffel3 and J.-P. Devogelaer
“Intermittent intravenous pamidronate effectively achieves primary prevention of GIOP, [glucocorticoid induced osteoporosis]as assessed by BMD measurements over 1 year. ” – given 30 mg pamidronate, intravenously, every 3 months plus 800 mg calcium/day.
abstract here:
http://www.springerlink.com/content/yt0fnt82926dba79/
This IV form however, runs the risk of jaw osteonecrosis:
discussion here:
http://painmuse.org/?p=173
-admin
I have polymyalgia rhumatica for about a yaer . My Dr. said it would probably be another year and then it will go away. I started with 50 mg. of prednisson dayly >now i am taking 2 1/2 mg. plus a few Advill during the day . My energy level is down , I have it in my shoulders , hipps and both hands . It always seams symetrical. Any sugestion for this misery.
10-13-2012 I first noticed symptoms in Feb of this year. Went to the emergency room in June with severe hip and back pain and was diagnosed with a reaction to lisiprel . Given predisone the pain quickly went away.I cant believe doctors.I was examined for hip ,back and wrist pain. Even had carpol tunnel surgery.And i was just diagnosed with polymyalgia reuhmatic. In this time I’ve had 7 cortisone shots in different parts of my body.Now about 20 mg of predone a day[ of which I have the doctors for] does the job.It took going to 6 doctors to finally figure this out.I’m sick of it . Not so much the disease but the doctors.They say try this dosage and come back in 2 months. well how bout it doesn’t work? I guess they dont give a shit if we suffer . They have to see more patients to make more money, so they dont have time for those that are suffering.
I agree – that is terrible. I have written a note specifically to address this:
Polymyalgia Rheumatica (PMR) Score – Using It for Steroid Dose
http://painmuse.org/?p=1705
-Admin