What is the diagnosis and treatment for Polymyalgia Rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) is best treated with oral prednisone starting at a dose within the range of 12.5–25 mg prednisone equivalent daily, with the specific dose determined by the patient's risk of relapse and side effects. This initial dose should be maintained until symptoms improve, then gradually tapered based on symptom control and inflammatory markers 1. The tapering schedule should be individualized, with a suggested initial tapering to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks, and subsequent tapering by 1 mg every 4 weeks until discontinuation, provided that remission is maintained 1.

Diagnosis and Treatment Considerations

• The diagnosis of PMR should be based on a comprehensive clinical evaluation, including the exclusion of mimicking conditions and the assessment of comorbidities and risk factors for steroid-related side effects 1.
• Patients should be monitored regularly for signs of relapse and side effects, with adjustments to the treatment plan as needed 1.
• Methotrexate may be considered as a steroid-sparing agent in cases of difficult tapering or prolonged therapy, at a dose of 7.5–10 mg/week 1.
• Calcium and vitamin D supplements should be taken during steroid therapy to prevent bone loss, and consideration should be given to adding a bisphosphonate if treatment extends beyond 3 months.

Key Recommendations

• The use of glucocorticoids (GCs) is strongly recommended over non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics for the treatment of PMR 1.
• The minimum effective dose of GCs should be used, with a recommended range of 12.5–25 mg prednisone equivalent daily 1.
• GC dose tapering should be individualized, with regular monitoring of patient disease activity, laboratory markers, and adverse events 1.
• Methotrexate may be considered as a steroid-sparing agent in cases of difficult tapering or prolonged therapy 1.

Follow-up and Monitoring

• Regular follow-up appointments every 1-3 months are necessary to assess response and adjust medication 1.
• Patients should be educated on the importance of monitoring for steroid side effects, including weight gain, mood changes, elevated blood sugar, and increased infection risk 1.
• Physical therapy and gentle exercise can help maintain muscle strength and joint mobility during recovery 1.

From the Research

Diagnosis of Polymyalgia Rheumatica (PMR)

• The diagnosis of PMR is aided by clinical symptoms, laboratory tests, and imaging studies 2
• Typical symptoms include acute or subacute bilateral shoulder pain with severe stiffness and often neck and bilateral hip pain 2
• C-reactive protein and erythrocyte sedimentation rates are elevated in over 90% of patients 2
• Imaging studies, especially ultrasonography and magnetic resonance imaging (MRI), can also aid in diagnosis 2

Treatment of Polymyalgia Rheumatica (PMR)

• Treatment currently consists of glucocorticoids at an initial dose of 12.5-25 mg prednisone equivalent daily 2
• The initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR 3
• Treatment duration is typically 2-3 years but may be longer 2
• Low-dose methotrexate can be used as adjuvant therapy under certain conditions 2
• Methotrexate is the most commonly used corticosteroid sparing agent 3
• Osteoporosis prophylaxis is also recommended 3

Response to Treatment

• Patients with PMR can be subdivided into distinct groups based on their response to treatment 4
• Some patients respond rapidly to treatment and require corticosteroids for less than 1 year, while others require longer treatment durations 4
• Pretreatment erythrocyte sedimentation rate and nonresponsiveness of interleukin 6 to steroid therapy are helpful in dividing patients into subsets with different treatment requirements 4
• Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 5