What is the first-line medication for managing polymyalgia rheumatica (PMR)?

From the Guidelines

Glucocorticoids, specifically prednisone, are the first-line medication for managing polymyalgia rheumatica (PMR). The typical starting dose is 12.5-25 mg of prednisone daily, with some patients responding to doses as low as 7.5-10 mg daily 1. After symptom control is achieved, usually within a few days to a week, the dose should be gradually tapered over months to the lowest effective dose that controls symptoms.

Key Considerations

• A common tapering schedule involves reducing the dose by 2.5 mg every 2-4 weeks until reaching 10 mg daily, then more slowly thereafter by 1 mg decrements 1.
• Most patients require treatment for 1-2 years, though some may need longer therapy.
• Glucocorticoids are effective in PMR because they suppress the underlying inflammatory process that causes the characteristic shoulder and hip girdle pain and stiffness.
• Patients should also take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements while on glucocorticoid therapy to prevent bone loss, and may need bisphosphonates if treatment extends beyond three months.
• Regular monitoring for glucocorticoid side effects and disease activity is essential during treatment 1.

Additional Recommendations

• The panel conditionally recommends considering intramuscular (i.m.) methylprednisolone as an alternative to oral GCs 1.
• Methotrexate (MTX) may be considered in patients at high risk for relapse and/or prolonged therapy, as well as in cases with risk factors, comorbidities, and/or concomitant medications where GC-related adverse events are more likely to occur 1.

From the Research

First-Line Management of Polymyalgia Rheumatica

The first-line management of polymyalgia rheumatica (PMR) involves the use of medications to reduce inflammation and alleviate symptoms. Based on the available evidence, the following options can be considered:

• Prednisone: This is a corticosteroid that is commonly used as the first-line treatment for PMR 2, 3, 4, 5. An initial dose of 10-20 mg/day can yield clinical improvement in the majority of patients with PMR, with improvement typically seen within 7 days of starting therapy.
• Methotrexate: This is a disease-modifying antirheumatic drug (DMARD) that can be used as a glucocorticoid-sparing agent in patients with PMR 2, 3, 4, 6, 5. However, its use is typically considered in patients who are at risk of glucocorticoid-related adverse events or who have a high risk of relapse.

Comparison of Treatment Options

The following options are not typically considered as first-line treatments for PMR:

• Cortisone injections: There is no evidence to suggest that cortisone injections are a first-line treatment for PMR.
• NSAIDs: While NSAIDs may be used to alleviate symptoms in some cases, they are not typically considered a first-line treatment for PMR.

Key Findings

Key findings from the available evidence include:

• Prednisone is the cornerstone of therapy in the management of patients with PMR 2.
• Methotrexate can be used as a glucocorticoid-sparing agent in patients with PMR, particularly in those at risk of glucocorticoid-related adverse events or who have a high risk of relapse 2, 3, 4, 6, 5.
• The optimal dose and duration of prednisone treatment for PMR are not well established, but an initial dose of 10-20 mg/day is commonly used, with tapering to a lower dose over time 2, 3, 5.