From the Guidelines
Polymyalgia rheumatica is typically treated with low-dose oral corticosteroids, primarily prednisone, starting at 12.5-25 mg daily, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.
Treatment Overview
The treatment of polymyalgia rheumatica (PMR) focuses on reducing inflammation and relieving symptoms. The use of glucocorticoids (GCs) is the cornerstone of treatment, with the goal of achieving the lowest effective dose to minimize side effects.
Initial Treatment
The initial dose of prednisone should be within the range of 12.5-25 mg daily, with a higher dose considered for patients at high risk of relapse and a lower dose for those with comorbidities or risk factors for GC-related side effects 1.
Dose Tapering
After 2-4 weeks of initial therapy, the dose can be gradually tapered by 1-2.5 mg every 2-4 weeks, based on symptom control and inflammatory markers (ESR/CRP) 1. The panel strongly recommends individualising dose tapering schedules, predicated on regular monitoring of patient disease activity, laboratory markers, and adverse events.
Maintenance Therapy
For maintenance, the goal is to reach the lowest effective dose, often 5-10 mg daily. Patients should take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements to prevent steroid-induced osteoporosis, and may need bisphosphonates if on long-term therapy.
Steroid-Sparing Agents
Steroid-sparing agents like methotrexate (10-25 mg weekly) may be added for patients who cannot tolerate steroids or have frequent relapses 1. Methotrexate has been shown to be effective in reducing cumulative GC doses and improving remission rates in PMR patients.
Monitoring
Regular monitoring of symptoms, inflammatory markers, blood glucose, and bone density is essential to adjust the treatment plan as needed and minimize the risk of adverse events.
Prognostic Factors
Female sex, high erythrocyte sedimentation rate (ESR), and peripheral arthritis have been identified as potential risk factors for a worse prognosis in PMR patients 1. However, the evidence for these factors is not consistent across all studies, and further research is needed to fully understand their impact on disease outcome.
From the Research
Treatment Overview
The treatment for Polymyalgia Rheumatica (PMR) typically involves the use of corticosteroids, such as prednisone or prednisolone, to control symptoms and suppress inflammation 2, 3, 4, 5, 6.
Corticosteroid Dosage
- The initial dosage of prednisone or prednisolone can range from 12.5 to 25 mg/day, with a common starting dose of 15 mg/day 2, 4, 6.
- The dosage can be tapered to a maintenance dose of 7.5 mg/day after 6-9 months 2.
- Some studies suggest that a rapid taper to 5 mg/day may be possible in some patients, followed by a prolonged period at this dose before further tapering 6.
Steroid-Sparing Agents
- Methotrexate has been shown to be effective as a steroid-sparing agent in PMR, allowing for lower doses of prednisone to be used 3, 5.
- Other biologic agents, such as tocilizumab and sarilumab, have also demonstrated efficacy in reducing relapse frequency and cumulative glucocorticoid burden 4.
Treatment Duration
- The duration of treatment with corticosteroids can vary, but some studies suggest that treatment can be stopped within 2 years of starting, although some patients may require longer treatment durations 2.
- The use of steroid-sparing agents, such as methotrexate, may help to reduce the duration of treatment with corticosteroids 3, 5.