What is the initial treatment for Polymyalgia Rheumatica (PMR)?

Initial Treatment for Polymyalgia Rheumatica (PMR)

The initial recommended treatment for Polymyalgia Rheumatica (PMR) is prednisone at a dose of 12.5-25 mg daily, followed by a structured tapering regimen to minimize side effects while maintaining disease control. 1

Glucocorticoid Therapy: The Cornerstone of PMR Treatment

• Initial prednisone dosing:

  • 12.5-25 mg daily is the recommended starting dose
  • Lower doses (≤7.5 mg/day) are insufficient for symptom control
  • Higher doses (>30 mg/day) are strongly discouraged due to increased adverse effects 1

• Expected response timeline:

  • Clinical improvement typically begins within days
  • Almost complete response expected within 4 weeks
  • Lack of response within this timeframe should prompt reconsideration of diagnosis 1

Tapering Protocol

A structured tapering regimen is essential to minimize relapse risk:

• Reduce to 10 mg/day within 4-8 weeks
• Then gradually reduce by 1 mg every 4 weeks until discontinuation 1
• Tapering prednisone too quickly (>1 mg/month) is associated with more relapses 1

Management of Relapses

If relapse occurs during tapering:

• Increase prednisone dose to the pre-relapse dose
• When symptoms are controlled, gradually decrease to the dose at which relapse occurred
• Resume slower tapering 1

Risk Factors for Relapse

Patients with the following characteristics may require more careful monitoring:

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

Adjunctive Therapy

Methotrexate

Methotrexate should be considered in specific situations:

• Patients with insufficient response to prednisolone
• Relapse during prednisolone tapering
• Patients experiencing glucocorticoid-related adverse events
• High-risk patients (female sex, peripheral inflammatory arthritis, comorbidities) 1

Dosage:

• 7.5-10 mg/week orally
• Higher doses (up to 25 mg/week) may be more effective for severe cases 1
• Research shows methotrexate can help reduce the cumulative prednisone dose and increase the likelihood of discontinuing prednisone 2

Additional Recommendations

• An individualized exercise program is recommended to maintain muscle mass and function and reduce fall risk 1
• Patient education about PMR and its treatment is crucial 1
• Regular monitoring:
  • Every 4-8 weeks in the first year
  • Every 8-12 weeks in the second year
  • More frequent during tapering or relapse 1
  • Monitor disease activity, ESR, CRP, and steroid-related side effects

Common Pitfalls and Caveats

1. Misdiagnosis: Ensure proper diagnosis before initiating treatment. Atypical presentation may require specialist referral 1

2. Inadequate initial dosing: Starting with doses <12.5 mg may lead to inadequate symptom control 1

3. Overly rapid tapering: Reducing prednisone too quickly increases relapse risk 1

4. Neglecting steroid-related complications: Monitor for and manage potential adverse effects of glucocorticoid therapy

5. Failure to recognize heterogeneity: PMR is a heterogeneous disease with variations in treatment duration and steroid requirements 3

6. NSAIDs are not recommended as primary treatment, except for short-term use for pain related to other conditions 1