From the Guidelines
For the emergent treatment of a polymyalgia rheumatica (PMR) flare, promptly increase the corticosteroid dose, typically prednisone, to the previous effective dose or by 5-10 mg per day if the current dose is insufficient, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1.
Key Considerations
- The initial increase in corticosteroid dose should be based on the patient's previous response to treatment and the severity of the flare.
- For a severe flare, consider increasing to 15-20 mg daily of prednisone, but be cautious of the potential for increased side effects.
- Once symptoms improve (usually within 2-3 days), begin a slow taper by reducing the dose by 1-2.5 mg every 2-4 weeks, based on symptom control and inflammatory markers, as suggested by the EULAR/ACR guidelines 1.
Additional Recommendations
- Supplement with calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) to prevent osteoporosis, especially in patients with a high risk of steroid-related side effects 1.
- Consider adding a proton pump inhibitor for gastrointestinal protection if using higher steroid doses, as recommended by the EULAR/ACR guidelines 1.
- For patients with frequent flares or steroid-dependent disease, adding a steroid-sparing agent like methotrexate (10-25 mg weekly) may be beneficial, as suggested by the EULAR/ACR guidelines 1.
Monitoring and Follow-up
- Patients should be monitored regularly, with follow-up visits every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as indicated in case of relapse or as prednisone is tapered and discontinued, as recommended by the EULAR/ACR guidelines 1.
- Continuous documentation of a minimal clinical and laboratory dataset should be conducted while prescribing GCs, including monitoring for side effects and adjusting the treatment plan as needed, as suggested by the EULAR/ACR guidelines 1.
From the FDA Drug Label
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. The emergent treatment for a Polymyalgia Rheumatica (PMR) flare is to return to a full suppressive daily divided corticoid dose for control, such as prednisone 2.
From the Research
Emergent Treatment for Polymyalgia Rheumatica (PMR) Flare
The emergent treatment for a PMR flare typically involves the use of glucocorticoids, such as prednisone or prednisolone, at a dose ranging between 12.5 and 25 mg/day 3. However, due to the side effects associated with prolonged glucocorticoid use, glucocorticoid-sparing agents have emerged as tools in the management of PMR.
Glucocorticoid-Sparing Agents
- Methotrexate has traditionally been the conventional disease-modifying antirheumatic drug (DMARD) unanimously recommended for use in PMR 3, 4.
- Other conventional DMARDs, such as leflunomide, have shown promising results but require further study 3.
- Biologic agents, such as tocilizumab and sarilumab, have demonstrated efficacy in reducing relapse frequency, lowering the cumulative glucocorticoid burden, and achieving long-term remission of the disease 3, 5.
Treatment Strategies
- An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR, generally achieved within 7 days of the onset of this therapy 4.
- Conditions different from isolated PMR should be considered in atypical cases or when a good response to 20 mg/day of prednisone is not achieved 4.
- Relapses of PMR are not uncommon when the dose of prednisone is equal to or below 5 mg/day 4, 6.
- A rapid taper of prednisone dose from 15 to 5 mg is possible in many patients with PMR, and a subsequent year of 5 mg/day before further tapering may result in a lower total dose of prednisone than with many previously recommended regimens 6.