Rare diseases

PMR triggered by immunotherapy may require lower doses of prednisolone


Polymyalgia rheumatica (PMR) that is triggered by immune checkpoint therapy can be treated with lower doses of prednisolone – between 5 mg to 7.5 mg per day –  than is currently recommended by guidelines to treat regular PMR, clinicians state.

Writing in the Annals of the Rheumatic Diseases, the rheumatologists from the Netherlands say their observation is important because prednisolone may compromise the efficacy of ICI therapy.

Their evaluation of six consecutive patients with ICI-PMR found that one patient could be managed with NSAIDs alone. Two patients required a prednisolone dose of 5–7.5 mg per day. Two other patients briefly required 15 mg of prednisolone per day before the doses was tapered to 7.5 mg.

The remaining patient, who was receiving 7.5 mg prednisolone per day due to hypophysitis/adrenal insufficiency, had their dose increased to 10mg per day and was also prescribed methotrexate because of ongoing concerns around the effects a higher dose of steroids would have on the efficacy of ICI therapy.

Prednisolone-free remission was obtained in three subjects. One patient went into remission despite continuation of ICI therapy, one reached prednisolone-free remission shortly after completion of ICI therapy and the third patient reached prednisolone-free remission at 1 year after the final ICI infusion.

“If systemic glucocorticoids are needed, a starting dose of 5–7.5 mg prednisolone per day might be sufficient in a substantial part of patients. Prompt response evaluation will identify patients in which the treatment should be stepped up … this approach will limit the use of prednisolone doses that might possibly compromise the efficacy of ICI therapy,” they concluded.

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