What is the starting dose of prednisone (corticosteroid) for Polymyalgia Rheumatica (PMR) and the recommended weaning regime?

Prednisone Dosing for Polymyalgia Rheumatica (PMR)

The recommended initial prednisone dose for PMR is 12.5-25 mg daily, with subsequent tapering to 10 mg/day within 4-8 weeks, followed by a gradual reduction of 1 mg every 4 weeks until discontinuation, as long as remission is maintained. 1, 2

Initial Dosing Considerations

• Starting dose range: 12.5-25 mg prednisone equivalent daily 1, 2

  • Higher doses within this range (closer to 25 mg) for patients with high relapse risk and low adverse event risk
  • Lower doses within this range (closer to 12.5 mg) for patients with comorbidities (diabetes, osteoporosis, glaucoma)
  • Doses ≤7.5 mg/day are discouraged (insufficient symptom control)
  • Doses >30 mg/day are strongly discouraged (increased adverse effects)

• Administration: Single daily oral dose in the morning (before 9 am) is preferred over divided doses 1, 2, 3

• Body weight consideration: Response to prednisone is related to body weight, with a target dose of approximately 0.19 mg/kg being effective for most patients 4

Tapering Schedule

1. Initial tapering phase:

   • Reduce dose to 10 mg/day within 4-8 weeks 1, 2

2. Maintenance tapering phase:

   • Once remission is achieved, taper by 1 mg every 4 weeks
   • Alternative: Use 1.25 mg decrements with alternate day schedules (e.g., 10/7.5 mg on alternate days) 1, 2
   • Slow tapering (<1 mg/month) is associated with fewer relapses 5

3. Duration of therapy:

   • Most patients can discontinue treatment within 1-2 years
   • Some patients may require treatment for up to 4 years 6
   • Continue tapering until discontinuation as long as remission is maintained 1

Relapse Management

If relapse occurs during tapering:

1. Increase prednisone to the pre-relapse dose
2. Gradually decrease (within 4-8 weeks) to the dose at which relapse occurred
3. Resume slower tapering when symptoms are controlled 1, 2

Monitoring Schedule

• Every 4-8 weeks during the first year
• Every 8-12 weeks during the second year
• More frequently during relapses or when tapering 1, 2

Steroid-Sparing Strategies

• Methotrexate: Consider early introduction (7.5-10 mg/week) for:
  • Patients at high risk for relapse or prolonged therapy
  • Patients with risk factors for glucocorticoid-related adverse events
  • Patients experiencing relapse or steroid-related adverse effects 1, 2, 7, 5

Common Pitfalls and Caveats

1. Inadequate initial dose: Starting with doses below 12.5 mg may lead to insufficient symptom control and potentially more relapses 1, 2

2. Too rapid tapering: Reducing prednisone faster than recommended increases relapse risk; slow tapering (<1 mg/month) is associated with better outcomes 5

3. Failure to adjust for body weight: Lower-weight patients may respond to lower doses; non-response in heavier patients may require dose adjustment based on weight (target ~0.19 mg/kg) 4

4. Inadequate monitoring: Regular assessment of disease activity, laboratory markers (ESR, CRP), and steroid-related side effects is essential 1, 2

5. Failure to consider steroid-sparing agents: Early introduction of methotrexate should be considered for patients at high risk of relapse or steroid-related complications 1, 2, 7