Methotrexate in Polymyalgia Rheumatica: Kernel of Truth or Curse of Tantalus?

In Greek mythology, King Tantalus, a son of Zeus, was a mortal favored by the gods. Invited to share ambrosia—food of the gods—Tantalus committed some unspecified breach of protocol, leading swiftly to his downfall. The unfortunate king was consigned to the lower world, there to undertake his punishment: eternal immersion in water up to his neck. More diabolically, whenever Tantalus tilted his head to drink, the water drained away. Although luscious fruit hung above him on trees, whenever he extended his arms to grasp it, winds blew the branches beyond reach. From Tantalus's name comes the English verb tantalize. In this issue, readers must decide whether Caporali and colleagues' randomized, double-blind, placebo-controlled trial of methotrexate in polymyalgia rheumatica (1) reveals a kernel of truth about methotrexate or bespeaks the curse of Tantalus: a desirable result placed just beyond the reach of those who would grasp it.

Few treatment responses in medicine rival the improvement in polymyalgia rheumatica wrought by prednisone. Regrettably, in some patients, repeated treatment courses necessitated by flare-ups engender long-term frustrations (and side effects) whose intensity may surpass even the exhilaration of those first days of prednisone therapy. Eventually, because of adverse glucocorticoid effects, some patients wonder whether the prescribed treatment is not closer to punishment than panacea. Rheumatologists have long sought a drug that would allow them to control polymyalgia rheumatica with less prednisone. Methotrexate has been their main hope.

Research on the potential efficacy of methotrexate's steroid-sparing effects in polymyalgia rheumatica and a related disorder, giant-cell arteritis, has been frustratingly inconclusive. In polymyalgia rheumatica, some studies have hinted at efficacy, yet the only …