What is the initial treatment for polymyalgia rheumatica (PMR)?

Initial Treatment for Polymyalgia Rheumatica (PMR)

The initial treatment for polymyalgia rheumatica is oral glucocorticoids (GCs) at a dose of 12.5-25 mg prednisone equivalent daily, with subsequent individualized tapering based on clinical response. 1

Glucocorticoid Therapy - First Line Treatment

Initial Dosing

• Use the minimum effective dose within 12.5-25 mg prednisone equivalent daily range
• Dosing considerations:
  • Higher initial dose (within range): For patients with high risk of relapse and low risk of adverse events
  • Lower initial dose (within range): For patients with relevant comorbidities (diabetes, osteoporosis, glaucoma) or other risk factors for GC-related side effects
  • Avoid initial doses ≤7.5 mg/day (conditionally discouraged)
  • Never use initial doses >30 mg/day (strongly discouraged) 1

Administration

• Use single rather than divided daily doses of oral GCs
• Exception: Consider divided dosing for prominent night pain when tapering below 5 mg daily 1

Tapering Schedule

Follow this evidence-based tapering protocol:

1. Initial tapering: Reduce dose to 10 mg/day prednisone equivalent within 4-8 weeks
2. For relapses: Increase to pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred
3. Once remission achieved: Taper by 1 mg every 4 weeks (or by 1.25 mg using alternate day schedules) until discontinuation 1

Alternative and Adjunctive Treatments

Intramuscular Methylprednisolone

• Consider as alternative to oral GCs (120 mg methylprednisolone IM every 3 weeks has been used in clinical trials)
• Choice between oral and IM remains at physician's discretion 1

Methotrexate (MTX)

• Consider early introduction (7.5-10 mg/week) in addition to GCs for:
  • Patients at high risk for relapse/prolonged therapy
  • Patients with risk factors, comorbidities or concomitant medications increasing likelihood of GC-related adverse events
  • Patients experiencing relapse without significant response to GCs
  • Patients experiencing GC-related adverse events 1
• Studies show MTX (10 mg/week) can reduce prednisone requirements and increase the proportion of patients able to discontinue prednisone 2

Treatment Monitoring

Follow-up Schedule

• Every 4-8 weeks in first year
• Every 8-12 weeks in second year
• As indicated for relapses or during prednisone tapering 1

Monitoring Parameters

• Steroid-related side effects
• Comorbidities
• Other relevant medications
• Evidence and risk factors for relapse/prolonged therapy
• Disease activity markers (ESR, CRP) 1

Important Caveats

Treatments to Avoid

• TNFα blocking agents (strongly recommended against)
• Chinese herbal preparations Yanghe and Biqi capsules (strongly recommended against)
• NSAIDs as primary therapy (use GCs instead) 1

Common Pitfalls

1. Inadequate initial dose: Starting with doses ≤7.5 mg/day may lead to insufficient symptom control
2. Overly aggressive tapering: Tapering faster than recommended increases relapse risk
3. Failure to consider steroid-sparing agents: Not considering methotrexate in appropriate patients
4. Inadequate monitoring: Not following patients closely enough during tapering
5. Overlooking comorbidities: Not accounting for diabetes, osteoporosis, or other conditions that may be worsened by GC therapy

Remember that PMR treatment should be based on shared decision-making between patient and physician, with an individualized management plan that considers patient preferences while following these evidence-based guidelines.