What is the treatment for Polymyalgia Rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica is primarily treated with oral glucocorticoids, with prednisone being the first-line therapy, starting with 12.5-25 mg daily, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The treatment typically begins with this dose, which usually produces dramatic symptom improvement within 24-48 hours.

• The initial dose should be individualized, with a higher dose considered in patients with a high risk of relapse and low risk of adverse events, and a lower dose in patients with relevant comorbidities 1.
• After 2-4 weeks of initial therapy with good symptom control, the dose should be gradually tapered by 1 mg every 4 weeks, or similar, once remission is achieved, as suggested by the panel 1.
• The total treatment duration typically ranges from 1-2 years, though some patients require longer therapy.
• For patients experiencing side effects or requiring prolonged treatment, steroid-sparing agents like methotrexate (7.5-10 mg weekly) may be added, as conditionally recommended by the panel 1.
• Calcium and vitamin D supplementation should be provided to all patients on glucocorticoids to prevent osteoporosis, and bisphosphonates should be considered for those at high fracture risk.
• Regular monitoring for steroid-related complications, such as diabetes, hypertension, weight gain, and cataracts, is essential, with patients evaluated every 4-8 weeks during treatment to assess symptom control and medication side effects, using ESR and CRP measurements to guide tapering decisions 1.
• Physical therapy and regular exercise help maintain muscle strength and function during treatment, as conditionally recommended by the panel 1.

From the FDA Drug Label

INDICATIONS AND USAGE PredniSONE Tablets are indicated in the following conditions: ... 2 Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: ... Although Polymyalgia Rheumatica (PMR) is not explicitly mentioned, it is a type of rheumatic disorder. The treatment for Polymyalgia Rheumatica (PMR) is not directly stated in the provided drug labels, but based on the information given, prednisone may be used as an adjunctive therapy for short-term administration to tide the patient over an acute episode or exacerbation in rheumatic disorders.

• The exact treatment regimen for PMR is not specified in the labels.
• Prednisone is indicated for various rheumatic disorders, but the labels do not provide explicit guidance on its use for PMR 2.

From the Research

Treatment Overview

• The treatment for Polymyalgia Rheumatica (PMR) is primarily based on low-dose glucocorticoids 3.
• Glucocorticoid-sparing agents, such as methotrexate, have also been tested and shown to be effective in reducing the dose of glucocorticoids needed 3, 4.

Glucocorticoid Treatment

• Starting prednisone doses higher than 10 mg/d are associated with fewer relapses and shorter therapy than lower doses 3.
• Starting prednisone doses of 15 mg/d or lower are associated with lower cumulative glucocorticoid doses than higher starting doses 3.
• Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 3.
• An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR 5.

Glucocorticoid-Sparing Agents

• Methotrexate seems to exert glucocorticoid-sparing properties and can be used as a steroid-sparing agent 3, 6, 4.
• Methotrexate is the most commonly used corticosteroid sparing agent in PMR treatment 5.
• The addition of oral or intramuscular methotrexate to prednisone treatment can provide efficacy at doses of 10 mg/wk or higher 3.

Treatment Duration and Relapses

• PMR is a heterogeneous disease with variations in treatment duration and dose of corticosteroids required for suppression of symptoms 7.
• Relapses of PMR are not uncommon when the dose of prednisone is equal to or below 5 mg/day 5.
• The duration of steroid therapy and the cumulative steroid dose can vary widely among patients with PMR 7.