From the Guidelines
The initial treatment recommendation for polymyalgia rheumatica (PMR) is low-dose oral prednisone, typically starting at 12.5-25 mg daily, as conditionally recommended by the panel 1. This corticosteroid therapy should be continued at the initial dose for 2-4 weeks until symptoms significantly improve, then gradually tapered over many months. A common tapering schedule involves reducing the dose by 1 mg every 4 weeks, or similar, once remission is achieved, as suggested by the panel 1. The panel strongly recommends individualising dose tapering schedules, predicated on regular monitoring of patient disease activity, laboratory markers, and adverse events 1. Most patients require treatment for 1-2 years, though some may need longer therapy. Calcium and vitamin D supplements should be added to prevent corticosteroid-induced osteoporosis, and a bisphosphonate may be indicated for those at high fracture risk. Some key points to consider in the management of PMR include:
- The use of intramuscular methylprednisolone as an alternative to oral GCs, with a starting dose of 120 mg every 3 weeks, as conditionally recommended by the panel 1
- The consideration of early introduction of methotrexate in addition to GCs, particularly in patients at a high risk for relapse and/or prolonged therapy, as conditionally recommended by the panel 1
- The importance of individualising exercise programmes for PMR patients, aimed at the maintenance of muscle mass and function, and reducing risk of falls, as conditionally recommended by the panel 1
- The strong recommendation against the use of TNFα blocking agents for treatment of PMR, as well as the use of Chinese herbal preparations Yanghe and Biqi capsules, as strongly recommended by the panel 1. Patients should be monitored regularly for symptom improvement, medication side effects, and potential disease complications, with ESR and CRP levels checked periodically to assess disease activity. The panel conditionally discourages low (≤7.5 mg/day) and strongly recommends against high (>30 mg/day equivalent) initial GC doses, as conditionally recommended by the panel 1. Methotrexate, as a steroid-sparing agent, is recommended in giant-cell arteritis and polymyalgia rheumatica, and can be considered in patients with systemic lupus erythematosus or (juvenile) dermatomyositis, as recommended by the multinational evidence-based recommendations 1.
From the FDA Drug Label
Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: ... No direct mention of polymyalgia rheumatica is found in the provided drug label.
The FDA drug label does not answer the question.
From the Research
Initial Treatment Recommendation for Polymyalgia Rheumatica
The initial treatment for polymyalgia rheumatica (PMR) is based on low-dose glucocorticoids, with the goal of achieving remission and minimizing side effects.
- The recommended starting dose of prednisone is between 12.5-25 mg per day, with 15 mg per day being a common initial dose 2, 3.
- The treatment duration is typically 2-3 years, but may be longer in some cases 3.
- Glucocorticoid-sparing agents, such as methotrexate, may be used as adjuvant therapy in certain cases, such as disease relapse or glucocorticoid-related adverse effects 4, 5, 3.
Factors Influencing Treatment
Several factors can influence the treatment of PMR, including:
- Disease severity and activity
- Presence of giant cell arteritis (GCA)
- Patient age and comorbidities
- Glucocorticoid-related adverse effects
- Response to initial treatment
Treatment Adjustments
Treatment adjustments may be necessary based on disease activity and patient response.