Complications
Characterized by frequent exacerbations of symptoms. May require treatment with higher doses of corticosteroids and the addition of a corticosteroid-sparing agent. The course of therapy may be prolonged.
Monitoring for infection should be a part of the regular follow-up. The risk can increase if higher doses are needed for prolonged periods of time.
A recognized complication of long-term corticosteroid use. Prophylaxis with calcium, vitamin D, and a bisphosphonate is indicated for patients taking prednisone >5 to 7.5 mg/day or its equivalent for more than 1 month.
An increased risk of the development of diabetes mellitus is associated with corticosteroid use.[62] Patients should have a baseline blood glucose and hemoglobin A1C checked. In patients with diabetes, the chronic use of corticosteroids may adversely affect glucose control, necessitating an adjustment of their diabetic treatment regimen.
Monitoring for muscle weakness should be a part of the regular follow-up. The risk can increase if higher doses are needed for prolonged periods of time.
Cardiovascular, cerebrovascular, and peripheral vascular event rates were higher in patients with PMR compared with those without from 6 months to 12 years of follow-up. The median 7.8-year risk was increased 2.6-fold. The risk was higher for patients younger than 60 years of age (5.6-fold).[63]
In patients on methotrexate, monitoring for myelosuppression (CBC) is recommended. The risk increases with increasing dose. Regular use of folic acid decreases risk.
In patients on methotrexate, monitoring for oral ulcers is recommended. The risk increases with increasing dose. Regular use of folic acid decreases risk.
In patients on methotrexate, monitoring hepatotoxicity (with liver function tests) is recommended. The risk increases with elevated doses. Concurrent alcohol use and nonessential hepatotoxic medications should be avoided.
A baseline CXR should be obtained prior to initiating dose, and use of another agent should be considered if there is evidence of underlying interstitial lung disease. In patients on methotrexate, clinicians should monitor for interstitial lung disease/alveolitis (new cough, shortness of breath, dyspnea on exertions, new rales on exam, and new interstitial changes on CXR). This is an idiosyncratic reaction, not a function of dose or duration of treatment.
Tocilizumab may increase the risk of serious liver injury (e.g., acute liver failure, hepatitis). Measure aminotransferase (ALT) and aspartate aminotransferase (AST) levels before initiation and every 4-8 weeks during the first 6 months of treatment. After the first 6 months, levels can be monitored every 12 weeks. Initiation of treatment is not recommended in patients with ALT or AST higher than 5-times the upper limit of normal. Patients should be advised to seek help immediately if they experience signs and symptoms of liver injury.[56]
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