What is the recommended initial treatment for polymyalgia rheumatica?

Initial Treatment for Polymyalgia Rheumatica

The recommended initial treatment for polymyalgia rheumatica is oral glucocorticoids at a dose of 12.5-25 mg prednisone equivalent daily, which should be tapered to 10 mg/day within 4-8 weeks. 1

Glucocorticoid Therapy Algorithm

Initial Dosing

• Use the minimum effective dose within 12.5-25 mg prednisone equivalent daily
• Dosing considerations:
  • Higher initial dose (closer to 25 mg) for patients with high risk of relapse but low risk of adverse events
  • Lower initial dose (closer to 12.5 mg) for patients with comorbidities (diabetes, osteoporosis, glaucoma)
  • Avoid initial doses ≤7.5 mg/day (conditionally discouraged)
  • Never use initial doses >30 mg/day (strongly discouraged)

Tapering Schedule

1. Initial tapering: Reduce dose to 10 mg/day within 4-8 weeks
2. Maintenance and further tapering: Once remission is achieved, taper by 1 mg every 4 weeks until discontinuation
3. Relapse management: Increase to pre-relapse dose and gradually decrease (within 4-8 weeks) to the dose at which relapse occurred

Alternative Administration Options

• Intramuscular methylprednisolone (120 mg injection every 3 weeks) can be considered as an alternative to oral glucocorticoids 1
• Single daily dosing is preferred over divided doses except in cases of prominent night pain when tapering below 5 mg daily 1

Adjunctive Therapy Considerations

• Consider early introduction of methotrexate (7.5-10 mg/week) in addition to glucocorticoids for:
  • Patients at high risk for relapse or prolonged therapy
  • Patients with risk factors for glucocorticoid-related adverse events
  • Patients experiencing relapse without significant response to glucocorticoids
  • Patients experiencing glucocorticoid-related adverse events 1

Monitoring and Follow-up

• Monitor patients every 4-8 weeks in the first year
• Monitor every 8-12 weeks in the second year
• Assess for:
  • Disease activity
  • Laboratory markers
  • Steroid-related side effects
  • Risk factors for relapse/prolonged therapy

Risk Factors for Prolonged Therapy/Relapse

• Female sex
• High ESR (>40 mm/1st hour)
• Peripheral inflammatory arthritis 1

Important Caveats

• NSAIDs are not recommended as primary treatment for PMR, though they may be used short-term for pain related to other conditions 1
• TNFα blocking agents are strongly discouraged for PMR treatment 1
• Individualized exercise programs are recommended to maintain muscle mass and function, especially in older patients on long-term glucocorticoids 1
• Patients with atypical presentations (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years) should be referred to specialists 1

Treatment Response Patterns

Research has identified heterogeneity in treatment response, with some patients requiring shorter courses of therapy (less than 1 year) while others need more prolonged treatment 2. Pretreatment ESR and IL-6 response to steroids may help predict treatment requirements, with persistently elevated IL-6 levels suggesting a more challenging treatment course.

The addition of methotrexate to prednisone has been shown to reduce the cumulative steroid dose and increase the proportion of patients able to discontinue prednisone therapy by 76 weeks 3, supporting its use in patients at high risk for steroid-related complications.