What is the initial treatment for polymyalgia rheumatica (PMR) with elevated Interleukin-6 (IL-6) levels?

Initial Treatment for Polymyalgia Rheumatica with Elevated IL-6 Levels

The initial treatment for polymyalgia rheumatica (PMR) with elevated IL-6 levels is oral prednisone at a dose of 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. 1

Glucocorticoid Therapy Protocol

Initial Dosing

• Starting dose: 12.5-25 mg prednisone daily
• Administration: Single morning dose (before 9 am) is preferred over divided doses
• Weight-based considerations: Response to prednisone is related to body weight, with an optimal dose of approximately 0.19 mg/kg 2
• Time to response: Clinical improvement typically occurs within 7 days of starting therapy 3

Tapering Schedule

• Reduce to 10 mg/day within 4-8 weeks
• Then gradually reduce by 1 mg every 4 weeks until discontinuation
• Slow tapering (<1 mg/month) is associated with fewer relapses 1, 4
• Doses ≤7.5 mg/day may provide insufficient symptom control
• Doses >30 mg/day are strongly discouraged due to increased adverse effects

Monitoring and Follow-up

• Regular assessment of:
  • Disease activity
  • Laboratory markers (ESR, CRP, IL-6)
  • Steroid-related side effects
• Follow-up frequency:
  • Every 4-8 weeks during the first year
  • Every 8-12 weeks during the second year
  • More frequently during relapses or when tapering

Steroid-Sparing Strategies

For patients with high risk of relapse, prolonged therapy, or steroid-related adverse events:

Methotrexate

• First-line steroid-sparing agent 1, 3
• Dosage: 7.5-10 mg/week orally
• Benefits: Reduces cumulative prednisone dose and increases likelihood of glucocorticoid discontinuation 5
• Indications for use:
  • High risk for relapse (female sex, high ESR >40 mm/hr, peripheral inflammatory arthritis)
  • Risk factors for glucocorticoid-related adverse events
  • Patients who have experienced a relapse
  • Inadequate response to glucocorticoids

Alternative Option

• Intramuscular methylprednisolone: 120 mg every 3 weeks until week 9, then tapered according to protocol 1

Management of Relapses

• If relapse occurs during tapering:
  • Increase prednisone to the pre-relapse dose
  • Gradually decrease (within 4-8 weeks) to the dose at which relapse occurred
  • Resume slower tapering when symptoms are controlled
  • Consider adding methotrexate if not already prescribed

Non-Recommended Treatments

• NSAIDs are not recommended as primary treatment
• TNFα blocking agents (including infliximab) are not recommended 1, 4
• Chinese herbal preparations Yanghe and Biqi capsules are not recommended

Special Considerations for IL-6 Elevation

While IL-6 levels are often elevated in PMR and may correlate with disease activity, standard glucocorticoid therapy remains the initial treatment of choice. Persistent elevation of IL-6 after 4 weeks of therapy despite improvement in ESR may indicate a subset of patients who will have a partial response and require longer treatment 6.

Common Pitfalls to Avoid

• Tapering prednisone too quickly (>1 mg/month) leads to more relapses
• Using divided steroid doses instead of a single morning dose
• Failing to provide osteoporosis prophylaxis 3
• Inadequate monitoring during tapering periods
• Not recognizing atypical presentations that may require specialist referral