What is the recommended treatment for managing Polymyalgia Rheumatica (PMR) symptoms?

Management of Polymyalgia Rheumatica (PMR) Symptoms

Glucocorticoids (GCs) are the cornerstone of PMR treatment, with an initial recommended dose of 12.5-25 mg prednisone equivalent daily, followed by a structured tapering schedule to minimize side effects while maintaining symptom control. 1

Initial Treatment Approach

First-line Therapy: Glucocorticoids

• Dosing recommendations:

  • Initial dose: 12.5-25 mg prednisone equivalent daily 1
  • Higher doses within this range for patients with high relapse risk and low adverse event risk
  • Lower doses for patients with comorbidities (diabetes, osteoporosis, glaucoma) 1
  • Strongly discouraged: Initial doses ≤7.5 mg/day or >30 mg/day 1

• Administration options:

  • Standard: Single daily oral dose (preferred over divided doses) 1
  • Alternative: Intramuscular methylprednisolone (120 mg every 3 weeks) may result in lower cumulative GC dose and less weight gain 2

Tapering Schedule

1. Initial tapering:

   • Reduce to 10 mg/day prednisone equivalent within 4-8 weeks 1

2. Maintenance tapering:

   • Once remission achieved: Taper by 1 mg every 4 weeks (or by 1.25 mg decrements using alternate day schedules) 1
   • Continue until discontinuation as long as remission is maintained

3. Relapse management:

   • Increase to pre-relapse dose
   • Gradually decrease (within 4-8 weeks) to the dose at which relapse occurred 1

Adjunctive Therapies

Methotrexate as Steroid-Sparing Agent

• Consider early introduction of methotrexate (7.5-10 mg/week) in addition to GCs for patients at high risk of relapse or prolonged therapy 2
• Benefits include:
  • Higher rates of GC discontinuation
  • Reduced cumulative GC dose
  • Potential bone preservation 3, 4

Non-Pharmacological Interventions

• Individualized exercise programs to maintain muscle mass and function 2
• Patient education about PMR and its treatment 1

Monitoring and Follow-up

• Regular monitoring is essential:

  • Every 4-8 weeks in first year
  • Every 8-12 weeks in second year
  • More frequently during relapses or tapering 1

• Assessment should include:

  • Disease activity
  • Laboratory markers (ESR, CRP)
  • Steroid-related side effects
  • Comorbidities
  • Risk factors for relapse/prolonged therapy 1

Special Considerations

Risk Factors for Relapse/Prolonged Therapy

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

Indications for Specialist Referral

• Atypical presentation (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years)
• High risk of or experiencing therapy-related side effects
• PMR refractory to GC therapy
• Relapses or need for prolonged therapy 1, 2

Contraindicated Therapies

• NSAIDs are not recommended as primary treatment (except for short-term use for pain related to other conditions) 1
• TNFα blocking agents are strongly discouraged 2

Common Pitfalls to Avoid

1. Inadequate initial dose: Starting with doses ≤7.5 mg/day may lead to insufficient symptom control
2. Overly aggressive initial dose: Using >30 mg/day increases risk of adverse effects without additional benefit
3. Too rapid tapering: May lead to disease flares and ultimately higher cumulative steroid exposure
4. Inadequate monitoring: Failure to regularly assess disease activity and steroid-related side effects
5. Missing atypical presentations: Consider specialist referral when presentation is unusual or response to treatment is inadequate

Remember that treatment should be based on shared decision-making between patient and physician, with an individualized management plan that considers patient preferences and comorbidities 1.