What is the initial treatment for polymyalgia rheumatica (PMR)?

Initial Treatment for Polymyalgia Rheumatica (PMR)

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

Corticosteroid Therapy Protocol

Initial Dosing

• Start with prednisone 12.5-25 mg/day (single morning dose before 9 AM)
• Clinical improvement typically occurs within 7 days of starting therapy 2
• If no response is achieved with 20 mg/day of prednisone, consider alternative diagnoses 2

Tapering Schedule

1. Reduce to 10 mg/day within 4-8 weeks
2. Then gradually reduce by 1 mg every 4 weeks until discontinuation
3. Maintain this slow tapering rate (<1 mg/month) to minimize relapses 1, 3

Monitoring During Treatment

• Follow-up every 4-8 weeks during the first year
• Follow-up every 8-12 weeks during the second year
• Monitor disease activity, ESR, CRP, and steroid-related side effects 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

Relapses are most common when prednisone doses are ≤5 mg/day 2, 3

Important Considerations and Cautions

Dosing Pitfalls

• Doses >30 mg/day are strongly discouraged due to increased adverse effects
• Doses ≤7.5 mg/day often provide insufficient symptom control
• Tapering too quickly (>1 mg/month) is associated with more relapses 1

Risk Factors for Prolonged Therapy or Relapse

• Female sex
• High ESR (>40 mm/1st hour)
• Peripheral inflammatory arthritis 1
• Elevated interleukin-6 levels that remain high despite treatment 4

Steroid-Sparing Strategies

For patients with high risk of steroid-related adverse events or relapsing disease:

Methotrexate

• Most effective steroid-sparing agent 1, 2
• Dosage: 7.5-10 mg/week orally 1
• Indications for adding methotrexate:
  • High risk for relapse or prolonged therapy
  • Risk factors for glucocorticoid-related adverse events
  • Relapsing disease
  • Inadequate response to glucocorticoids
  • Experiencing glucocorticoid-related adverse events 1, 5

Non-Recommended Treatments

• NSAIDs are not recommended as primary treatment
• TNFα blocking agents are strongly discouraged
• Chinese herbal preparations (Yanghe and Biqi capsules) are not recommended 1

Supportive Care

• Osteoporosis prophylaxis is recommended 2
• Individualized exercise program to maintain muscle mass and function 1

The evidence strongly supports using prednisone as first-line therapy, with careful attention to dosing and tapering schedules to minimize both disease activity and steroid-related complications. The most recent guidelines emphasize the importance of not tapering too quickly and considering methotrexate as a steroid-sparing agent in appropriate patients.