Short-course prednisone and methotrexate in a cohort of patients with polymyalgia rheumatica: a potential therapeutic approach

The optimal treatment of polymyalgia rheumatica (PMR) is far from being fully elucidated. Only a few trials explored the role of conventional DMARDs: none of them adequately ruled out subclinical giant cell arteritis (GCA). The aim of this study was to assess whether the precocious administration of methotrexate (MTX) and a short course of glucocorticoids (GCs) could be safe and effective in recently diagnosed PMR. Patients with a recent diagnosis of PMR were prospectively enrolled, upon exclusion of GCA, and treated with MTX and gradually tapered prednisone (PDN). As a control group, a historical cohort treated with GC-monotherapy was included. The primary endpoint was PDN-free remission at 24 weeks. Secondary endpoints were sustained remission at 52 weeks, number of relapses, PDN dosage, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 26 and 52 weeks, compared to historical cohort. The prospective and historical cohorts included 41 and 63 patients, respectively. In the MTX-group, at 26 weeks, 66% of patients were in steroid-free remission and a significant reduction of CRP and ESR was observed, while mean daily PDN dosage dropped to 3.42 mg. Twenty-four subjects reached 52-week phase of the study and 83% maintained GC-free remission. A higher number of relapses were reported in the retrospective cohort (12, 27% vs. 34, 43%), in which up to 49 patients were still taking PDN. In conclusion, upon a subclinical GCA is excluded, MTX at adequate dosages, is a suitable option for the treatment of PMR, allowing a precocious discontinuation of oral GCs. Methotrexate could be effective in the treatment of polymyalgia rheumatica. The precocious administration of methotrexate could allow an early discontinuation of oral glucocorticoids.