Treatment with prednisone, 15 mg/d, is appropriate. This 74-year-old man presents with shoulder and hip girdle pain and limitation accompanied by signs of systemic inflammation, including low-grade fever, weight loss, malaise, and a markedly elevated erythrocyte sedimentation rate (ESR). This constellation of findings is classic for polymyalgia rheumatica (PMR), especially in this age group. Treatment of PMR, typically prednisone initiated at a dose of 10 to 20 mg/d, is warranted and should result in rapid resolution of symptoms. Prednisone can be tapered over a 6-month period in some patients, but others experience flares with tapering and require more prolonged therapy, for as long as 1 to 3 years. Methotrexate can be tried as a glucocorticoid-sparing agent, but studies suggest limited efficacy.
Low-dose aspirin (81 mg/d) may be useful to reduce ocular complications in patients with giant cell arteritis (GCA), which can co-occur with PMR; however, this patient has no signs or symptoms consistent with GCA such as jaw claudication, temporal headache, or visual loss.
Aspirin, 650 mg three times daily, functions in a manner similar to other traditional NSAIDs, with analgesic, anti-inflammatory, and antipyretic effects. However, like other NSAIDs, it is not a treatment for PMR and is not effective for this condition.
Duloxetine is a dual serotonin-norepinephrine reuptake inhibitor that is used as an antidepressant, to modulate pain due to fibromyalgia and other chronic central pain syndromes, and for chronic musculoskeletal pain. Although the patient has pain and a depressed affect—a common constellation in fibromyalgia—his pain is in a classic distribution for PMR and his depressed affect is common in patients with PMR pain. Since low-dose prednisone will likely be curative, duloxetine therapy should not be needed.
High-dose prednisone is indicated for GCA and severe or life-threatening forms of autoimmunity but carries a high rate of toxicity. This patient has no signs or symptoms of GCA or any other disease except PMR; therefore, high-dose prednisone is not warranted.