Case study 1. Disease control
A 70-year-old woman experiences bilateral shoulder and hip pain and
stiffness. She is diagnosed with polymyalgia rheumatica and commences
treatment with prednisolone 15mg daily. After 3 weeks her symptoms have
disappeared and she is advised to reduce her prednisolone dose to 12.5
mg for 3 weeks, then to 10 mg for 4 weeks, then by 1mg per month
[25]. Three months later her concerned son tells her GP that she is
fatigued and depressed and can’t get out of bed or the bath. On enquiry
she stopped her prednisolone after 6 weeks of treatment because of
concerns about weight gain.
Discussion. Polymyalgia rheumatica (PMR) is an inflammatory
musculoskeletal disorder of unknown aetiology, which classically
responds well to systemic glucocorticoids. The treatment regimen
described here is based on the recommendations of the British Society
for Rheumatology and British Health Professionals in Rheumatology
[25] and is consistent with the example tapering regimen shown in
table 2.
This patient stopped glucocorticoid treatment abruptly after 6 weeks of
treatment. At this point rapid withdrawal could cause disease relapse or
adrenal insufficiency. The systemic features of PMR e.g. fatigue,
anorexia, fever, weight loss and depression can be difficult to
distinguish from the symptoms of adrenal insufficiency. Raised
inflammatory markers (C-reactive protein, erythrocyte sedimentation
rate) would be supportive of disease reactivation. As she has now not
had glucocorticoids for ~9 weeks, one approach would be
to recommence treatment for PMR at 15mg/day followed by the taper as
planned. A key issue for this patient would be to discuss the benefits
of the treatment in the context of her concerns about taking
glucocorticoids to encourage her to adhere to treatment. Advice on
avoiding weight gain with glucocorticoids could also be helpful (e.g.
NHS guidance [38]). If she recommences glucocorticoid treatment, she
should be advised not to stop prednisolone abruptly and provided with a
steroid card.