What is the typical steroid course for polymyalgia rheumatica (PMR)?

Steroid Course for Polymyalgia Rheumatica

The recommended initial prednisone dose for polymyalgia rheumatica (PMR) is 12.5-25 mg/day, followed by a structured tapering schedule with initial reduction to 10 mg/day within 4-8 weeks, then gradual reduction by 1 mg every 4 weeks until discontinuation. 1

Initial Treatment Phase

• The European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) guidelines strongly recommend against initial doses >30 mg/day and conditionally discourage doses ≤7.5 mg/day as insufficient for symptom control 1
• The initial dose should be individualized based on patient weight, with approximately 0.19 mg/kg being effective for most patients 2
• Clinical response typically occurs within 7 days of starting therapy 3
• If symptoms do not improve within 7 days, alternative diagnoses should be considered 1

Tapering Schedule

The EULAR/ACR guidelines recommend a structured tapering approach:

1. Initial tapering: Reduce to 10 mg/day within 4-8 weeks
2. Maintenance tapering: Once remission is achieved, taper by 1 mg every 4 weeks (or using alternate-day schedules like 10/7.5 mg) until discontinuation 1
3. Relapse management: If relapse occurs, increase prednisone to the pre-relapse dose and then gradually decrease (within 4-8 weeks) to the dose at which relapse occurred, then resume slower tapering 1

Alternative Administration and Adjunctive Therapy

• Single vs. divided doses: A single daily dose is conditionally recommended over divided doses, except in cases with prominent night pain while on low doses (<5 mg daily) 1
• Intramuscular methylprednisolone: May be considered as an alternative to oral glucocorticoids (120 mg IM injection every 3 weeks has been used in clinical trials) 1
• Methotrexate: Consider early introduction (7.5-10 mg/week) in addition to glucocorticoids for patients at high risk for relapse, prolonged therapy, or glucocorticoid-related adverse events 1, 4

Special Considerations

• Risk stratification: Patients with higher initial pain scores and persistently elevated interleukin-6 levels despite treatment may require longer therapy 5
• Weight-based dosing: Body weight significantly affects response to prednisone therapy, with lighter patients typically responding better to standard doses 2
• Exercise program: An individualized exercise program is conditionally recommended to maintain muscle mass and function and reduce fall risk, especially in older or frail patients 1

Common Pitfalls and Caveats

• Inadequate initial dosing: Starting with doses ≤7.5 mg/day often results in inadequate symptom control 1
• Overly aggressive initial dosing: Doses >30 mg/day increase adverse effects without providing additional benefit 1
• Too rapid tapering: Approximately 65% of patients relapse when prednisone is reduced too quickly, particularly below 10 mg/day 6
• Failure to recognize GCA development: About 15% of PMR patients may develop giant cell arteritis during treatment, requiring higher steroid doses 6
• Overlooking steroid-sparing options: Methotrexate can reduce cumulative steroid exposure and should be considered early in high-risk patients 4
• Monitoring limitations: ESR and CRP may not reliably predict relapse during tapering 6

Treatment Duration

• Most patients require 1-2 years of therapy, though some may need treatment for shorter (<1 year) or longer periods 5
• The decision to discontinue therapy should be based on sustained clinical remission and normalization of inflammatory markers 1