From the Guidelines
For a 75-year-old with polymyalgia rheumatica (PMR) awaiting a rheumatology appointment, a reasonable starting prednisone dose is typically 15-20 mg once daily, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. This initial dose is generally effective for symptom relief while balancing the risk of side effects in older adults. The patient should take the medication in the morning with food to minimize gastrointestinal irritation.
After starting treatment, they should expect symptom improvement within 24-72 hours; lack of response may suggest an alternative diagnosis. While waiting for the specialist, the patient should monitor for side effects including increased blood sugar, blood pressure changes, mood alterations, sleep disturbances, and increased infection risk. Regular blood pressure and glucose checks are advisable, as older adults are at a higher risk of developing steroid-related side effects, such as osteoporosis, glaucoma, and diabetes 1.
The patient should not stop the medication abruptly and should bring a record of their response to treatment to the rheumatologist appointment. The specialist will likely create a personalized tapering schedule, as PMR typically requires 1-2 years of gradually decreasing therapy. This moderate starting dose provides symptom control while minimizing the risk of steroid-related complications in older patients. According to the guidelines, the initial tapering should aim to reduce the dose to 10 mg/day prednisone equivalent within 4-8 weeks, and subsequent tapering should be done by 1 mg every 4 weeks until discontinuation, given that remission is maintained 1.
Key considerations for the patient include:
- Monitoring for side effects and reporting any changes in their condition to their healthcare provider
- Adhering to the prescribed medication regimen and not stopping the medication abruptly
- Keeping a record of their response to treatment to share with the rheumatologist
- Following up with regular appointments to adjust the treatment plan as needed. The guidelines also recommend considering comorbidities, other relevant medications, and possible risk factors for steroid-related side effects when determining the initial dose and tapering schedule 1.
From the Research
Treatment of Polymyalgia Rheumatica (PMR)
- The primary treatment for PMR is glucocorticoids, with prednisone or prednisolone at a dose ranging between 12.5 and 25 mg/day 2, 3, 4.
- For a 75-year-old patient with PMR, a reasonable dose of prednisone while waiting for a rheumatologist appointment would be between 12.5 and 25 mg/day 2, 3, 4.
Glucocorticoid-Sparing Agents
- Methotrexate is a conventional disease-modifying antirheumatic drug (DMARD) that can be used as an adjuvant therapy to reduce the dose of prednisone 5, 6.
- The use of methotrexate has been shown to allow for a lower cumulative dose of prednisone and reduce the frequency of relapses 5, 6.