Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
Intern Med J. 2020 Sep;50(9):1067-1072. doi: 10.1111/imj.14779.
Current guidelines recommend methotrexate (MTX) as a glucocorticoid-sparing agent in patients with polymyalgia rheumatica (PMR) who relapse or suffer glucocorticoid adverse effects, although there is no level 1 evidence to support this recommendation.
To review the effect of MTX in PMR on inflammation and glucocorticoid dose.
Patients with PMR from rheumatology outpatient clinics at two tertiary centres were identified. A structured case note review was conducted for patient characteristics at diagnosis and medications including glucocorticoid and MTX use.
There were 70 patients, 61% female; mean (range) age of 70 (51-87) years. At the time of diagnosis, median (±interquartile range) erythrocyte sedimentation rate (ESR) was 38.5 (26-74) mm/h and C-reactive protein (CRP) 34.5 (6-74 mg/L) with median initiating prednisolone dose of 15 mg (range 5-60 mg). MTX was prescribed in 22 (31%) patients. Mean disease duration at MTX initiation was 2.5 years (1-7 years), with median (range) MTX dose of 10 mg (5-20 mg). At MTX initiation, median (interquartile range) (±standard deviation) ESR was 33 (13-60 mm/h) and CRP 19 (8-42 mg/L). Reasons for commencing MTX were disease relapse (34%) or inability to wean prednisolone dose (66%). Six months after MTX initiation, there was significant reduction in ESR (P = 0.012), CRP (P = 0.0003) and prednisolone dose (P < 0.0001). Eleven (50%) patients stopped MTX, five due to controlled PMR, and six due to adverse effects.
In this study of PMR patients in tertiary care, 31% were co-prescribed MTX, after prolonged disease duration. MTX was associated with improved inflammatory activity and reduced prednisolone dose, with a relatively high risk of adverse events.
目前的指南建议在患有巨细胞动脉炎（PMR）的患者中，在复发或出现糖皮质激素不良反应时，使用甲氨蝶呤（MTX）作为糖皮质激素保留剂，尽管没有一级证据支持这一建议。
回顾 MTX 在 PMR 中的作用，包括对炎症和糖皮质激素剂量的影响。
在两个三级中心的风湿科门诊中，确定了患有 PMR 的患者。对患者的特征、诊断时的药物治疗（包括糖皮质激素和 MTX 的使用）进行了结构化病历回顾。
共有 70 名患者，61%为女性；平均（范围）年龄为 70（51-87）岁。在诊断时，中位（±四分位间距）红细胞沉降率（ESR）为 38.5（26-74）mm/h，C 反应蛋白（CRP）为 34.5（6-74）mg/L，起始泼尼松剂量中位数为 15 mg（范围 5-60 mg）。22（31%）名患者开具了 MTX。开始使用 MTX 的平均疾病病程为 2.5 年（1-7 年），MTX 剂量中位数为 10 mg（5-20 mg）。在开始使用 MTX 时，中位（四分位间距）（±标准差）ESR 为 33（13-60 mm/h），CRP 为 19（8-42 mg/L）。开始使用 MTX 的原因是疾病复发（34%）或无法逐渐减少泼尼松剂量（66%）。开始使用 MTX 6 个月后，ESR（P = 0.012）、CRP（P = 0.0003）和泼尼松剂量（P < 0.0001）显著降低。11（50%）名患者停用 MTX，其中 5 名因 PMR 得到控制，6 名因不良反应停用。
在这项对三级护理中 PMR 患者的研究中，31%的患者在疾病持续较长时间后同时开具了 MTX。MTX 与改善炎症活动度和减少泼尼松剂量有关，但不良反应风险相对较高。
