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.