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Articles: Roberto Caporali, Marco A. Cimmino, Gianfranco Ferraccioli, Roberto Gerli, Catherine Klersy, Carlo Salvarani, Carlomaurizio Montecucco for the Systemic Vasculitis Study Group of the Italian Society for Rheumatology Prednisone plus Methotrexate for Polymyalgia Rheumatica: A Randomized, Double-Blind, Placebo-Controlled Trial Ann Intern Med 2004; 141: 493-500 [Abstract] [Full text] [PDF]

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The use of methotrexate in the early treatment of polymyalgia rheumatica

Mitsumasa Kishimoto, Wen Dombrowski, Steven B. Abramson   (11 November 2004)

Methotrexate in Polymyalgia Rheumatica

Francisco R. Lafita, Belinda Garcia MD   (13 October 2004)

The use of methotrexate in the early treatment of polymyalgia rheumatica 11 November 2004
Mitsumasa Kishimoto, MD Department of Rheumatology, New York University/Hospital for Joint Diseases, Wen Dombrowski, Steven B. Abramson Send rapid response to journal: Re: The use of methotrexate in the early treatment of polymyalgia rheumatica kishimotomi{at}aol.com Mitsumasa Kishimoto, et al.	Caporali and colleagues reported that combination therapy with prednisone and methotrexate can be effective in polymyalgia rheumatica and reduce the incidence of flare-ups and the amount of prednisone required to maintain remission (1). This is a well done study, but we have concerns that an unintended consequence of the study will be to promote the use of methotrexate as a first line agent in PMR. The prednisone sparing effect is most (1mg) and since there were no reports of an increased risk of development of Giant Cell Arteritis in the prednisone only group, it is not clear that the use of initial methotrexate provided a meaningful clinical benefit. Moreover, this approach would unnecessarily expose a large number of elderly patients with PMR to treatment with methotrexate. A future study should involve testing the Caporali protocol versus the conventional treatment aproach, namely, the addition of methotrexate to prednisone "failures". Clinically meaningful outcomes would then be the prevention of GCA and serious steroid toxicity (2-5). Therefore, we believe that clinicians should not alter their practice to include the use of methotrexate as an adjunct to prednisone in the early treatment of polymyalgia rheumatica until further studies address these issues. References 1. Caporali R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, Montecucco C. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2004 Oct 5;141(7):493-500. 2. Salvarani C, Gabriel SE, O'Fallon WM, Hunder GG. The incidence of giant cell arteritis in Olmsted County, Minnesota: apparent fluctuations in a cyclic pattern. Ann Intern Med. 1995 Aug 1;123(3):192-4. 3. Brooks RC; McGee SR. Diagnostic dilemmas in polymyalgia rheumatica. Arch Intern Med. 1997 Jan 27;157(2):162-8. 4. Gonzalez-Gay MA, Hajeer AH, Dababneh A, Makki R, Garcia-Porrua C, et al. Seronegative rheumatoid arthritis in elderly and polymyalgia rheumatica have similar patterns of HLA association. J Rheumatol. 2001 Jan;28(1):122-5. 5. Hoffman GS, Cid MC, Hellmann DB, Guillevin L, Stone JH, et al. A multicenter, randomized, double-blind, placebo-controlled trial of adjuvant methotrexate treatment for giant cell arteritis. Arthritis Rheum. 2002 May;46(5):1309-18. Conflict of Interest: None declared
Methotrexate in Polymyalgia Rheumatica 13 October 2004
Francisco R. Lafita, MD, FACP Gabinet Mèdic. Cambrils 43850 Baix Camp. Spain, Belinda Garcia MD Send rapid response to journal: Re: Methotrexate in Polymyalgia Rheumatica frlafita{at}ilarportal.org Francisco R. Lafita, et al.	Caporalli and colleagues (1) have presented a well conducted study on the steroid’ sparing effect of methotrexate in polymyalgia rheumatica (PMR). Previous studies (2,3) have failed to show any benefit of methotrexate on PMR but others (4) found some evidence of it. Often PMR requires a course of treatment through 1-2 years and in some cases it can be longer (5). However Caporalli and colleagues study is based in a fast tapering of prednisone (24 weeks) and a short follow up of patients (18 months). Moreover, no data on new flares and the appearing of other related diseases (GCA, R3SPE) after 18 months were found. It should be interesting to know how long the remissions lasted behind that period and if differences in relapses between both groups were found and what treatment was then applied. 1. Caporalli R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, Montecucco C. Prednisone plus methotrexate for polymyalgia rheumatica. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2004;141:493-501. 2. Feinberg HL, Sherman JD, Schrepferman CG, Dietzen CJ, Feinberg GD. The use of methotrexate in polymyalgia rheumatica. J Rheumatol. 1996;23(9):1550-2. 3. van der Veen MJ, Dinant HJ, van Booma-Frankfort C, van Albada- Kuipers GA, Bijlsma JW. Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis? Ann Rheum Dis. 1996;55(4):218-23. 4. Ferraccioli G, Salaffi F, De Vita S, Casatta L, Bartoli E. Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol. 1996;23(4):624-8. 5. Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica. Best Pract Res Clin Rheumatol. 2004;18(5):705-22. Conflict of Interest: None declared