What is the recommended taper plan for prednisone in a patient with Polymyalgia Rheumatica (PMR)?

From the Guidelines

For patients with Polymyalgia Rheumatica (PMR), the recommended taper plan for prednisone is to taper the dose by 1 mg every 4 weeks once remission is achieved, as suggested by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.

Key Principles of Tapering

• Initial tapering: Taper dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks 1.
• Relapse therapy: Increase oral prednisone to the pre-relapse dose and decrease it gradually (within 4–8 weeks) to the dose at which the relapse occurred 1.
• Tapering once remission is achieved: Taper daily oral prednisone by 1 mg every 4 weeks (or by 1.25 mg decrements using schedules such as 10/7.5 mg alternate days, etc) until discontinuation given that remission is maintained 1.

Considerations

• The panel strongly recommends individualising dose tapering schedules, predicated to regular monitoring of patient disease activity, laboratory markers and adverse events 1.
• The choice of tapering schedule should be based on the individual patient's response to treatment and risk of relapse 1.
• Calcium and vitamin D supplementation should be provided throughout treatment to prevent osteoporosis, and bone density monitoring is recommended.
• Some patients may require steroid-sparing agents like methotrexate if they cannot tolerate the taper or have significant steroid-related side effects 1.

From the Research

Taper Plan for PMR

The recommended taper plan for prednisone in patients with Polymyalgia Rheumatica (PMR) is as follows:

• Starting prednisone doses higher than 10 mg/d are associated with fewer relapses and shorter therapy than lower doses 2
• Starting prednisone doses of 15 mg/d or lower are associated with lower cumulative glucocorticoid doses than higher starting doses 2
• Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 2
• One study suggested tapering prednisone dosage (25 mg/d) to 0 mg/d within 24 weeks and adjusting if flare-ups occur 3
• Another study attempted to stop prednisone after 6 months and used the lowest possible dose over the next 6 months 4

Factors Influencing Taper Plan

Several factors can influence the taper plan, including:

• Initial prednisone dose: higher doses may be associated with fewer relapses, but also with more glucocorticoid-related adverse effects 2
• Presence of giant cell arteritis (GCA): patients with GCA may require longer treatment duration and higher prednisone doses 5
• Use of methotrexate as a steroid-sparing agent: methotrexate may allow for lower cumulative prednisone doses and fewer relapses, but its effectiveness as a steroid-sparing agent is still debated 3, 4, 6

General Guidelines

General guidelines for tapering prednisone in PMR patients include:

• Tapering the dose gradually to minimize the risk of relapse 2
• Monitoring the patient's symptoms and laboratory results (e.g., C-reactive protein, erythrocyte sedimentation rate) to adjust the taper plan as needed 5
• Considering the use of methotrexate or other steroid-sparing agents in patients at high risk of steroid-related toxicity or with a history of relapses 3, 4