What is the recommended initial treatment for polymyalgia rheumatica?

Initial Treatment for Polymyalgia Rheumatica

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

Prednisone Dosing and Tapering Schedule

• Initial dose: 12.5-25 mg daily (single morning dose)
• Tapering schedule:
  • Reduce to 10 mg/day within 4-8 weeks
  • Then gradually reduce by 1 mg every 4 weeks until discontinuation
  • Maintain this slow tapering schedule as long as remission is maintained

Tapering prednisone too quickly (>1 mg/month) is associated with more relapses. Doses ≤7.5 mg/day are discouraged due to insufficient symptom control, while doses >30 mg/day are strongly discouraged due to increased adverse effects 1.

Monitoring and Follow-up

• Regular assessment of disease activity, laboratory markers (ESR, CRP), and steroid-related side effects
• Follow-up every 4-8 weeks during the first year
• 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

Risk Factors for Relapse or Prolonged Therapy

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

Steroid-Sparing Agents

For patients at high risk for relapse, prolonged therapy, or steroid-related adverse events, methotrexate is the most effective steroid-sparing alternative:

• Dosage: 7.5-10 mg/week orally
• Benefits: Improved remission rates and reduced cumulative glucocorticoid doses 1, 2

Special Considerations

• NSAIDs are not recommended as primary treatment, except for short-term use for pain related to other conditions 1
• TNFα blocking agents and Chinese herbal preparations Yanghe and Biqi capsules are not recommended for PMR treatment 1
• An individualized exercise program is conditionally recommended to maintain muscle mass and function and reduce risk of falls 1

Common Pitfalls to Avoid

1. Starting with too high a dose: Starting doses >30 mg/day increase adverse effects without providing additional benefit 1
2. Tapering too quickly: Tapering faster than 1 mg/month increases relapse risk 1, 3
3. Inadequate monitoring: Failure to regularly assess disease activity and steroid-related side effects can lead to suboptimal outcomes 1
4. Overlooking heterogeneity: PMR is a heterogeneous disease with variations in treatment duration and corticosteroid requirements 4
5. Failing to consider steroid-sparing agents: For patients at high risk of steroid-related complications, methotrexate should be considered early 1, 2