More is less: Glucocorticoid-sparing agents in polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is one of the most common inflammatory rheumatic diseases in older adults. Glucocorticoids (GC) are very effective in treating PMR, but their use is associated with adverse events such as infections, osteoporosis or ophthalmological diseases. In patients with relapsing PMR and long-term GC dependency or those with an initial high risk of GC-related toxicity, GC-sparing agents can be used to minimize GC exposure. Several substances have been tested in clinical trials. Methotrexate was commonly used in the past decades, but the interleukin (IL)-6 receptor inhibitor sarilumab is the first (and currently only) GC-sparing agent approved for use in PMR in the United States and Europe. Sarilumab was able to decrease cumulative GC exposure and increase the probability of achieving remission in a recent trial. In the foreseeable future, janus kinase inhibitors and IL-17 inhibitors might join the treatment armamentarium of GC-sparing agents in PMR. Additionally, the 11β-hydroxysteroid dehydrogenase type 1 inhibitor clofutriben has shown promise in protecting against GC toxicity. This review summarizes real-world evidence on GC use and associated toxicity in patients with PMR, puts data from relevant trials into context and explores future directions in the treatment of patients with PMR.