From the Guidelines
The typical treatment for Polymyalgia Rheumatica (PMR) is low-dose oral corticosteroids, primarily prednisone, starting at 12.5-25 mg daily. This recommendation is based on the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The treatment usually begins with this initial dose for 2-4 weeks until symptoms improve, followed by a slow, gradual tapering schedule over 1-2 years to prevent relapse.
Key Considerations
- The dose is typically reduced by 1-2.5 mg every 2-4 weeks, with slower reductions at lower doses 1.
- Patients should take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements while on corticosteroid therapy to prevent bone loss.
- Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential side effects is essential.
- Some patients may require steroid-sparing agents like methotrexate if they cannot tolerate steroids or experience frequent relapses 1.
Tapering Schedule
The panel suggested prednisone should be tapered by 1 mg/4 weeks or similar once remission is achieved 1. However, the panel emphasized the important overall principle of gradual GC reduction without the need to prescribe a fixed schedule.
Alternative Treatments
Intramuscular (i.m.) methylprednisolone may be considered as an alternative to oral GCs, particularly in cases where a lower cumulative GC dose is desirable 1. However, the panel did not endorse a strong recommendation for the use of i.m. methylprednisolone due to the lack of convincing evidence showing significantly fewer side effects compared to oral GC therapy 1.
Patient Education
Patients should be aware that symptom improvement is often dramatic within days of starting treatment, but premature discontinuation of steroids commonly leads to relapse, necessitating the long, careful tapering process. Corticosteroids are effective because they suppress the inflammatory process that causes the muscle pain and stiffness characteristic of PMR.
From the Research
Treatment Overview
The typical treatment for Polymyalgia Rheumatica (PMR) involves the use of glucocorticoids, with prednisone or prednisolone being the most commonly used medications 2, 3. The initial dose of prednisone is usually between 10-20 mg/day, which yields clinical improvement in the majority of patients with PMR within 7 days of the onset of this therapy 3.
Glucocorticoid-Sparing Agents
Due to the side effects associated with prolonged glucocorticoid use, glucocorticoid-sparing agents have emerged as tools in the management of PMR. Methotrexate is the most commonly used corticosteroid sparing agent 4, 5, 3, 6. Other conventional disease-modifying antirheumatic drugs (DMARDs), such as leflunomide, have shown promising results but require further study 2.
Biologic Agents
The use of biologic agents has marked a significant step forward in the management of PMR. Anti-IL-6 receptor agents, such as tocilizumab and sarilumab, have demonstrated efficacy in reducing relapse frequency, lowering the cumulative glucocorticoid burden, and achieving long-term remission of the disease 2.
Key Points
- Prednisone or prednisolone at a dose ranging between 12.5 and 25 mg/day is the agreed-upon treatment for PMR 2.
- Methotrexate has traditionally been the conventional disease-modifying antirheumatic drug (DMARD) unanimously recommended for use in PMR 4, 5, 3, 6.
- Biologic agents, such as tocilizumab and sarilumab, offer alternatives to traditional therapies, improving symptoms and reducing glucocorticoid use 2.
- Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 6.