Pain Management for Polymyalgia Rheumatica
Glucocorticoids (GCs) are the first-line treatment for pain management in polymyalgia rheumatica (PMR), with NSAIDs and analgesics playing only a limited role for pain related to other conditions. 1
First-Line Treatment: Glucocorticoids
Initial Dosing
- Starting dose: 12.5-25 mg prednisone equivalent daily 1
- Lower starting doses (12.5-15 mg/day) are sufficient for approximately 75% of patients 2
- Weight-based dosing is important - responders typically receive about 0.19 mg/kg compared to 0.16 mg/kg in non-responders 2
- Higher doses within the range (20-25 mg) may be needed for patients with higher body weight or more severe symptoms
- Avoid initial doses ≤7.5 mg/day (insufficient) or >30 mg/day (excessive side effects) 1
Administration Method
- Single morning dose is preferred over divided doses 1
- Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral therapy, particularly in patients with comorbidities like diabetes, osteoporosis, or hypertension 1, 3
- Methylprednisolone may provide faster symptom relief (15.2 days) compared to prednisone (20.3 days) 3
Tapering Schedule
- Initial tapering: Reduce to 10 mg/day within 4-8 weeks 1
- Maintenance tapering: Once remission is achieved, taper by 1 mg every 4 weeks 1
- Slow tapering (<1 mg/month) is associated with fewer relapses than faster tapering regimens 4
Second-Line/Adjunctive Treatments
Methotrexate
- Consider early introduction of methotrexate (7.5-10 mg/week) in addition to GCs for: 1, 5
- Patients at high risk for relapse
- Those with risk factors for GC-related adverse events
- Patients experiencing relapses or GC-related side effects
- Methotrexate has demonstrated steroid-sparing effects, allowing more patients to discontinue prednisone (88% vs 53%) 5
NSAIDs and Analgesics
- NSAIDs are not recommended as primary treatment for PMR 1
- Short-term use of NSAIDs or analgesics may be considered only for pain related to other conditions 1
- No specific recommendation can be made for simple analgesics in PMR 1
Non-Pharmacological Approaches
- Individualized exercise program is recommended to maintain muscle mass and function, especially in older patients on long-term GCs 1
Treatment Monitoring
- Monitor patients every 4-8 weeks in the first year, then every 8-12 weeks in the second year 1
- Assess for:
- Disease activity
- Laboratory markers (ESR, CRP)
- Steroid-related side effects
- Risk factors for relapse
Important Caveats
- Response to treatment is diagnostic: Significant improvement should occur within 7 days of starting appropriate GC therapy 6
- Consider alternative diagnoses if there is inadequate response to 20 mg/day of prednisone 6
- Relapses are common when prednisone dose is reduced to ≤5 mg/day 6
- Osteoporosis prophylaxis is recommended for patients on long-term GC therapy 6
- Avoid TNFα blocking agents as they are not effective in PMR 1
Special Considerations
- For night pain during low-dose tapering (<5 mg prednisone), divided dosing may be considered 1
- Patients with higher body weight may require higher initial doses within the recommended range 2
- Women may respond better to lower doses due to typically lower body weight 2
By following this approach, most patients with PMR can achieve effective pain control while minimizing the risks associated with glucocorticoid therapy.