What is the recommended corticosteroid treatment regimen for polymyalgia rheumatica (PMR)?

From the Guidelines

The recommended corticosteroid treatment regimen for polymyalgia rheumatica (PMR) should start with oral prednisone at a dose of 12.5-25 mg daily, as conditionally recommended by the panel 1. This initial dose is usually maintained for 2-4 weeks until symptoms significantly improve, after which a slow, gradual tapering schedule should be implemented. The tapering generally involves reducing the dose by 1 mg every 4 weeks, as suggested by the panel 1, with the goal of reaching the lowest effective maintenance dose. Some key points to consider in the management of PMR include:

• The use of the minimum effective individualised duration of GC therapy in PMR patients, as strongly recommended by the panel 1
• The use of a single rather than divided daily doses of oral GCs for the treatment of PMR, as conditionally recommended by the panel 1
• The consideration of early introduction of methotrexate (MTX) 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 regular monitoring for steroid-related side effects, including diabetes, hypertension, and osteoporosis, as well as the use of calcium and vitamin D supplementation to prevent corticosteroid-induced osteoporosis. During tapering, if symptoms flare, the dose should be temporarily increased to the last effective dose before attempting to taper again, as suggested by the principles of GC dose tapering 1. Alternative corticosteroids like methylprednisolone or deflazacort can be used in patients who cannot tolerate prednisone, as conditionally recommended by the panel 1. Corticosteroids are effective in PMR because they suppress the inflammatory process that causes the characteristic shoulder and hip girdle pain and stiffness in this condition. It is essential to individualise dose tapering schedules, predicated on regular monitoring of patient disease activity, laboratory markers, and adverse events, as strongly recommended by the panel 1.

From the Research

Corticosteroid Treatment Regimen for Polymyalgia Rheumatica

The recommended corticosteroid treatment regimen for polymyalgia rheumatica (PMR) typically involves the use of prednisone. Key points to consider include:

• The initial dose of prednisone, which can range from 10-25 mg/day, with most patients experiencing a rapid response within 7 days 2, 3, 4.
• The starting dose may be related to body weight, with lower weight patients potentially requiring lower doses 3.
• A dose of 12.5-15 mg/day is often considered sufficient for most patients, with higher doses potentially leading to more glucocorticoid-related adverse effects 3, 5.
• The tapering regimen is also important, with slow tapering (<1 mg/mo) associated with fewer relapses and more frequent glucocorticoid treatment cessation 5.

Factors Influencing Treatment Response

Several factors can influence the response to corticosteroid treatment in PMR, including:

• Body weight, with lower weight patients potentially responding better to lower doses 3.
• Disease severity, although there is limited evidence to suggest that higher doses are necessary for more severe disease 2, 5.
• The presence of other conditions, such as giant cell arteritis, which may require different treatment approaches 4.

Alternative Treatment Regimens

Alternative treatment regimens, such as a rapid taper of prednisone dose from 15 to 5 mg, followed by a prolonged period at 5 mg/day, may be as efficacious as traditional regimens and lead to shorter treatment courses 6. However, these regimens require further study to fully establish their efficacy and safety. Methotrexate is also commonly used as a corticosteroid-sparing agent in PMR, particularly for patients who experience relapses or require long-term glucocorticoid treatment 2, 5, 4.