From the Guidelines
The management of polymyalgia rheumatica (PMR) primarily involves low-dose oral corticosteroids, typically prednisone starting at 12.5-25 mg daily, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.
Key Principles of PMR Management
- The initial dose of prednisone should be individualized within the range of 12.5-25 mg daily, considering the risk of relapse and side effects 1.
- The dose should be tapered gradually to minimize the risk of relapse, with an initial tapering to 10 mg/day prednisone equivalent within 4-8 weeks 1.
- Patients should be monitored regularly for symptom recurrence, inflammatory markers (ESR/CRP), blood glucose, and blood pressure 1.
- Steroid-sparing agents like methotrexate (10-25 mg weekly) may be considered in steroid-dependent cases or when side effects become problematic 1.
- Calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation should be prescribed to prevent osteoporosis, and bisphosphonates may be indicated for high-risk patients 1.
Important Considerations
- The treatment plan should be individualized based on patient preferences, comorbidities, and risk factors for side effects 1.
- Patients should have access to education and advice on individually tailored exercise programs to maintain muscle strength and joint mobility 1.
- Regular follow-up visits are essential to monitor disease activity, adjust treatment, and prevent complications 1.
Evidence-Based Recommendations
- The use of intramuscular methylprednisolone as an alternative to oral GCs may be considered, with a starting dose of 120 mg every 3 weeks 1.
- Methotrexate has been shown to be effective in reducing cumulative GC doses and improving remission rates in PMR patients 1.
- Anti-tumor necrosis factor α agents are not recommended for the treatment of PMR due to lack of efficacy 1.
From the Research
Management of Polymyalgia Rheumatica (PMR)
The management of PMR involves the use of glucocorticoids, such as prednisone or prednisolone, as the primary treatment [ 2, 3, 4, 5 ]. The initial dose of prednisone is typically between 10-20 mg/day, with clinical improvement usually achieved within 7 days [ 5 ].
Glucocorticoid Tapering
Glucocorticoid tapering is a crucial aspect of PMR management, with the goal of minimizing the risk of relapse and reducing the cumulative glucocorticoid burden [ 2, 3, 4 ]. A slow tapering regimen, with a reduction of less than 1 mg/month, is often recommended [ 3, 4 ].
Glucocorticoid-Sparing Agents
Glucocorticoid-sparing agents, such as methotrexate, have been shown to be effective in reducing the cumulative glucocorticoid burden and achieving long-term remission [ 2, 3, 4, 5 ]. Biologic agents, such as tocilizumab and sarilumab, have also demonstrated efficacy in reducing relapse frequency and achieving long-term remission [ 2, 3 ].
Additional Considerations
Other considerations in the management of PMR include:
- Osteoporosis prophylaxis, which is recommended to prevent glucocorticoid-induced osteoporosis [ 5 ]
- The use of amino bisphosphonates, which may be associated with glucocorticoid discontinuation [ 6 ]
- Individualization and close monitoring of treatment, as the response to treatment can vary significantly between patients [ 3 ]
Key Points
- Glucocorticoids are the primary treatment for PMR
- Glucocorticoid tapering should be done slowly to minimize the risk of relapse
- Glucocorticoid-sparing agents, such as methotrexate and biologic agents, can be effective in reducing the cumulative glucocorticoid burden and achieving long-term remission
- Osteoporosis prophylaxis and individualization of treatment are important considerations in the management of PMR [ 2, 3, 4, 5, 6 ]