Treatment Overview

Corticosteroid medicine is the most common treatment for both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). People with either or both conditions usually have fast relief of their symptoms soon after starting corticosteroid treatment.

Initial treatment

Corticosteroid medicine treats both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). Generally, you will use the corticosteroids at a certain dose until your symptoms go away and your lab tests are normal. When this occurs, your doctor will gradually begin reducing your medicine.

For polymyalgia rheumatica:

• You take lower doses of corticosteroids than in giant cell arteritis, generally 5 mg to 20 mg per day.²
• You are likely to have a lot of pain relief in a few days, and symptoms usually go away and your lab results are normal in 2 to 3 weeks. If your symptoms don't start going away within 2 to 4 days, your doctor may give you a higher dose (possibly 30 mg daily) and do further testing to be sure your condition is polymyalgia rheumatica.
• After your symptoms go away and your laboratory tests are normal, your doctor will gradually lower your dose, generally every few weeks.
• You will probably have to take corticosteroids for about 2 years or more to prevent the symptoms from returning (relapse). Some people only need to take the medicine for less than a year.

For giant cell arteritis:

• You take higher doses of corticosteroids than used in polymyalgia rheumatica, generally 40 mg to 60 mg per day.² Because giant cell arteritis can cause serious complications, such as stroke or blindness, your doctor may start treatment immediately, even if the diagnosis has not been confirmed by tests.
• You are likely to have a lot of pain relief in a few days, and symptoms usually go away and your lab results are normal in 2 to 4 weeks. If your symptoms don't start to go away, your doctor may give you a higher dose.
• After your symptoms go away and your lab tests are normal, your doctor will gradually lower your dose, generally every 2 to 4 weeks in the first several months, then less often after that.
• You will probably have to take corticosteroids for 1 to 2 years to prevent relapse, although about half of the people with the condition need them for longer than 2 years.³

See a table comparing corticosteroid treatment of polymyalgia rheumatica and giant cell arteritis.

How long you need to take corticosteroids depends on how severe your condition is, whether it appears cured or not (remission), and how often you have relapses. Some people are not able to completely stop taking corticosteroids over time. If this happens, your doctor may suggest another medicine such as methotrexate to help control your symptoms and keep the condition from coming back.

Ongoing treatment

After your symptoms have gone away and your laboratory tests are normal, ongoing treatment for polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) usually includes continued use of corticosteroid medicine.

Your doctor gradually lowers the amount of medicine you take. How quickly he or she does this varies with the individual.

• In polymyalgia rheumatica, most people have to take corticosteroids for about 2 years, although some people need them for less than a year.
• In giant cell arteritis, most people have to take corticosteroids for 1 to 2 years, although about half of the people with the condition need them for longer than 2 years.³

If your symptoms do not improve with corticosteroid medicine, your doctor may need to test you for other conditions that are similar to polymyalgia rheumatica or giant cell arteritis.

Your doctor will track your condition while you are taking corticosteroid medicine and for 6 to 12 months after you stop taking the medicine. This tracking may include regular appointments or telephone calls to discuss your symptoms and tests to measure your erythrocyte sedimentation rate (ESR) or your C-reactive protein (CRP) value.

See a table comparing corticosteroid treatment of polymyalgia rheumatica and giant cell arteritis.

If you need long-term corticosteroid treatment for either condition, you are at risk for bone thinning (osteoporosis). This is because corticosteroids decrease how well your body takes in calcium, which is important in building strong bones. Your doctor may recommend a bone density (DEXA) test to see if you need medicine (bisphosphonates) to prevent osteoporosis, or he or she may simply start you on bisphosphonates without the test. For more information, see the topic Osteoporosis.

Treatment if the conditions get worse

In both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), your symptoms may return (relapse) after a period of improvement. This often occurs within the first 2 years of treatment or during the first 12 months after you stop taking corticosteroid medicine. A relapse usually occurs if the dose of corticosteroids is reduced or withdrawn too quickly. But up to 50% of people with either condition have a relapse over the first 2 years that is not related to how corticosteroids are used.¹ If you have a relapse of symptoms, your doctor will increase the corticosteroid dosage for a period of time, then gradually decrease it after your symptoms are gone.

See a table comparing corticosteroid treatment of polymyalgia rheumatica and giant cell arteritis.

In rare cases, giant cell arteritis can affect the main part of the aorta in the chest, rather than one of its smaller branches, causing an aortic aneurysm. If this were to happen, you would feel severe chest pain that could extend to your back, and you could faint or have symptoms of a stroke. If you have giant cell arteritis and have such symptoms, contact your doctor or call 911 immediately. Though rare, such an event may be life-threatening. Your doctor may recommend that you have a chest X-ray for several years after completing your treatment, to watch for an aortic aneurysm.²

Up to 20% of people with untreated giant cell arteritis experience partial or complete loss of vision in one or both eyes.¹ If you have sudden onset of double, blurred, or "browned-out" vision, or temporary loss of vision, your doctor may increase your corticosteroid dose, and you may get it directly into a blood vessel (intravenously) for a few days to prevent permanent or further loss of vision.

What to think about

If you have polymyalgia rheumatica and do not have giant cell arteritis, your doctor may suggest using nonsteroidal anti-inflammatory drugs (NSAIDs) when you are lowering the dose of your corticosteroid medicine. Always talk to your doctor or nurse before using these medicines.

Some doctors recommend taking aspirin if you have giant cell arteritis. This is because some studies show that doing so may reduce the risk of vision loss, stroke, or transient ischemic attacks (blood flow to the brain is interrupted).⁴

Corticosteroids can cause serious side effects, including high blood pressure (hypertension) and bone thinning (osteoporosis). If you are taking long-term corticosteroids to treat polymyalgia rheumatica or giant cell arteritis:

• You must also take 1000 mg to 1500 mg of calcium daily and 800 IU of vitamin D daily.
• You may also need bisphosphonate medicine such as alendronate or risedronate to prevent bone loss.
• You can help reduce the risk of osteoporosis by lifting weights and doing weight-bearing exercise such as walking. For more information, see the topic Osteoporosis.
• Your doctor may suggest that you take a proton pump inhibitor such as Prilosec or a medicine called an H2 blocker (acid reducer) to protect your digestive (gastrointestinal or GI) tract, including your esophagus and stomach. Taking a lot of medicine for a long period of time can irritate these areas and can even lead to ulcers. Proton pump inhibitors and H2 blockers decrease the amount of acid the stomach makes. This reduces irritation of the stomach and can help reduce irritation of the esophagus.

Methotrexate or other medicines that suppress your immune system, such as azathioprine, may be used in polymyalgia rheumatica or giant cell arteritis alone or with corticosteroids to reduce the corticosteroid dose and limit its side effects. Research results are mixed on how effective this treatment is.^{3, 5}

Giant cell arteritis sometimes affects the large arteries of the arm. In rare cases, this interferes with blood flow. This can cause pain and cramping when you use your arm. In a small study, balloon angioplasty opened up the arteries of the arm to decrease symptoms of giant cell arteritis.⁶