What is the recommended initial treatment for polymyalgia rheumatica?

Initial Treatment for Polymyalgia Rheumatica

The recommended initial treatment for polymyalgia rheumatica (PMR) is prednisone at a dose of 12.5-25 mg daily, taken as a single morning dose before 9 am. 1

Glucocorticoid Therapy Protocol

Initial Dosing and Tapering

• Start with prednisone 12.5-25 mg daily (single morning dose)
• Taper to 10 mg/day within 4-8 weeks
• Further reduce by 1 mg every 4 weeks until discontinuation, as long as remission is maintained 1
• Avoid tapering too quickly (>1 mg/month) as this is associated with more relapses 1
• Avoid doses ≤7.5 mg/day (insufficient symptom control) and >30 mg/day (increased adverse effects) 1

Monitoring During Treatment

• Assess disease activity, laboratory markers (ESR, CRP), and steroid-related side effects regularly
• Follow-up every 4-8 weeks during the first year
• Follow-up every 8-12 weeks during the second year
• More frequent monitoring during relapses or when tapering 1

Management of Relapses

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

Steroid-Sparing Agents

Methotrexate

Methotrexate (7.5-10 mg/week orally) should be considered for patients with:

• High risk for relapse or prolonged therapy
• Risk factors for glucocorticoid-related adverse events
• History of relapse
• Inadequate response to glucocorticoids
• Glucocorticoid-related adverse events 1

Research has shown that prednisone plus methotrexate is associated with shorter prednisone treatment duration and steroid-sparing effects 2.

Intramuscular Methylprednisolone

An alternative steroid-sparing option with the following regimen:

• 120 mg every 3 weeks until week 9
• 100 mg at week 12
• Monthly injections with dose reduction of 20 mg every 12 weeks until week 48
• Further reduction by 20 mg every 16 weeks until discontinuation 1

Risk Factors for Relapse or Prolonged Therapy

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

Non-Recommended Treatments

• NSAIDs are not recommended as primary treatment (may be used short-term for pain related to other conditions) 1
• TNFα blocking agents are not recommended 1
• Chinese herbal preparations Yanghe and Biqi capsules are not recommended 1

Special Considerations

• PMR is a heterogeneous disease with variations in treatment duration and corticosteroid requirements 3
• Patients with higher pretreatment pain scores and persistent elevation of interleukin-6 despite therapy may have a partial response to initial steroid regimen 3
• An individualized exercise program is recommended to maintain muscle mass and function and reduce risk of falls 1

Common Pitfalls to Avoid

1. Starting with too low a dose of prednisone (inadequate symptom control)
2. Starting with too high a dose (unnecessary side effects)
3. Tapering too quickly (increased risk of relapse)
4. Failing to monitor for steroid-related complications
5. Not considering steroid-sparing agents in high-risk patients

Research suggests that slow prednisone dose tapering (<1 mg/month) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 4.