What are the management options for recurrent Polymyalgia Rheumatica (PMR) symptoms?

From the Guidelines

The management of recurrent Polymyalgia Rheumatica (PMR) symptoms should prioritize adjusting glucocorticoid therapy, considering steroid-sparing agents, and ensuring regular monitoring to minimize morbidity, mortality, and improve quality of life.

Key Considerations

• For patients experiencing a flare while on treatment, the first step is to increase the prednisone dose, usually by 5-10 mg/day above the dose at which symptoms recurred, then gradually tapering again once symptoms resolve, as suggested by the 2015 recommendations for the management of PMR 1.
• The initial GC dose should be within a range of 12.5–25 mg prednisone equivalent daily, with a higher initial prednisone dose considered in patients with a high risk of relapse and low risk of adverse events 1.
• Methotrexate (7.5–10 mg/week) is conditionally recommended for early introduction in addition to GCs, particularly in patients at a 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.

Monitoring and Adjustments

• Regular monitoring is essential, with clinical assessments every 4-8 weeks during flares and laboratory tests including ESR and CRP to track inflammation, and consideration of specialist referral in case of atypical presentation or refractory disease 1.
• Patients should have access to education focusing on the impact of PMR and treatment, including comorbidities and disease predictors, and advice on individually tailored exercise programmes to maintain muscle mass and function, and reduce the risk of falls 1.

Additional Considerations

• The use of TNFα blocking agents is strongly recommended against for the treatment of PMR 1.
• Calcium and vitamin D supplementation (1000-1200 mg calcium and 800-1000 IU vitamin D daily) may be beneficial for patients on long-term steroid use to prevent osteoporosis.
• Recurrent symptoms may sometimes indicate an alternative diagnosis, so reassessment is important if symptoms persist despite appropriate treatment adjustments.

From the FDA Drug Label

The benefits of alternate day therapy should not encourage the indiscriminate use of steroids. In the event of an acute flare-up of the disease process, it may be necessary to return to a full suppressive daily divided corticoid dose for control. Once control is again established alternate day therapy may be re-instituted Although many of the undesirable features of corticosteroid therapy can be minimized by alternate day therapy, as in any therapeutic situation, the physician must carefully weigh the benefit-risk ratio for each patient in whom corticoid therapy is being considered. Other symptomatic therapy may be added or increased at this time if needed.

The management options for recurrent Polymyalgia Rheumatica (PMR) symptoms include:

• Returning to a full suppressive daily divided corticoid dose for control in the event of an acute flare-up
• Re-instituting alternate day therapy once control is again established
• Adding or increasing other symptomatic therapy as needed
• Carefully weighing the benefit-risk ratio for each patient in whom corticoid therapy is being considered 2 Polymyalgia Rheumatica (PMR) is not explicitly mentioned in the provided drug labels, but the information on alternate day therapy and management of disease flare-ups can be applied to the management of recurrent PMR symptoms.

From the Research

Management Options for Recurrent PMR Symptoms

The management of recurrent Polymyalgia Rheumatica (PMR) symptoms primarily involves the use of corticosteroids, with the goal of achieving clinical improvement while minimizing side effects.

• Corticosteroids, such as prednisone, are the cornerstone of PMR treatment, with an initial dose of 10-20 mg/day yielding clinical improvement in the majority of patients within 7 days 3.
• The dose of prednisone can be tapered to 5 mg/day or lower, but relapses are not uncommon when the dose is equal to or below 5 mg/day 3.
• Methotrexate is the most commonly used corticosteroid-sparing agent, allowing for the use of lower doses of prednisone and reducing the risk of osteoporosis 3, 4.
• Other treatment options, such as azathioprine, may also be used as steroid-sparing agents 5.
• The optimal tapering regimen for prednisone is not well established, but slow tapering (<1 mg/mo) may be associated with fewer relapses and more frequent glucocorticoid treatment cessation 6.

Corticosteroid Tapering Regimens

Different tapering regimens have been studied, including:

• A rapid taper of prednisone dose from 15 to 5 mg/day, followed by a year of 5 mg/day before further tapering 7.
• A slow tapering regimen of less than 1 mg/mo, which may be associated with fewer relapses and more frequent glucocorticoid treatment cessation 6.
• A maintenance dose of 7.5 mg prednisolone/day after 6-9 months, with the goal of minimizing relapses and allowing for steroid withdrawal within 2 years of starting treatment 5.

Glucocorticoid-Sparing Agents

Glucocorticoid-sparing agents, such as methotrexate, may be used to reduce the dose of prednisone required to control PMR symptoms.

• Methotrexate has been shown to be effective in reducing the dose of prednisone required to control PMR symptoms, and may also help to prevent osteoporosis 4, 6.
• Other glucocorticoid-sparing agents, such as azathioprine, may also be used, but their efficacy and safety in PMR treatment are not as well established 5.