Which specialty manages Polymyalgia Rheumatica (PMR) and who should I consult to taper or stop long-term steroids in a patient with PMR?

Management of Polymyalgia Rheumatica: Specialty Care and Steroid Tapering

Polymyalgia rheumatica (PMR) should be managed by rheumatologists, especially for patients on long-term steroids who need tapering, and you should refer your patient to rheumatology for steroid discontinuation assessment. 1

Specialty Management of PMR

Rheumatologists are the primary specialists who manage PMR for several important reasons:

• PMR is a rheumatologic condition requiring expertise in inflammatory disorders
• Rheumatologists have specific training in glucocorticoid (GC) management and tapering strategies
• They can differentiate PMR from other mimicking conditions that may require different treatment approaches

When to Refer to Rheumatology

The 2015 EULAR/ACR guidelines specifically recommend specialist referral in the following situations 1:

• Atypical presentation (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years)
• High risk of or experiencing therapy-related side effects
• PMR refractory to GC therapy
• Relapses or need for prolonged therapy
• For assessment and management of steroid discontinuation

Steroid Tapering in PMR

When considering tapering steroids in a patient with PMR, the following approach is recommended:

1. Initial assessment before tapering:

   • Confirm disease is in remission (absence of symptoms and normalized inflammatory markers)
   • Evaluate for risk factors for relapse (female sex, high ESR >40 mm/hr, peripheral inflammatory arthritis)
   • Assess for steroid-related complications

2. Recommended tapering schedule:

   • Once remission is achieved, taper daily oral prednisone by 1 mg every 4 weeks
   • Alternative schedules include 1.25 mg decrements using alternate day schedules (e.g., 10/7.5 mg alternate days)
   • Continue gradual reduction until discontinuation as long as remission is maintained 1

3. Monitoring during tapering:

   • Regular follow-up visits (every 4-8 weeks in first year, every 8-12 weeks in second year)
   • Monitor for symptoms of relapse and inflammatory markers
   • Assess for steroid-related side effects

Management of Relapse During Tapering

If relapse occurs during tapering:

• Increase oral prednisone to the pre-relapse dose
• Once symptoms resolve, resume tapering more gradually (within 4-8 weeks) 1

Steroid-Sparing Strategies

For patients with difficulty tapering steroids or at high risk for steroid-related complications:

• Consider methotrexate (MTX) as a steroid-sparing agent at doses of 7.5-10 mg/week 1, 2

• MTX is particularly useful for:

  • Patients at high risk for relapse or prolonged therapy
  • Those with risk factors for GC-related adverse events
  • Patients who have relapsed or experienced GC-related adverse events 1

• Alternative GC administration: Consider intramuscular methylprednisolone as an alternative to oral prednisone in select patients 1

Important Caveats and Pitfalls

• Avoid abrupt discontinuation of steroids in PMR patients on long-term therapy due to risk of adrenal insufficiency
• Do not use NSAIDs as primary treatment for PMR (except for short-term pain management for other conditions) 1
• Strongly avoid TNFα blocking agents as they are not recommended for PMR treatment 1
• Do not use very low initial doses (≤7.5 mg/day) as they are insufficient to control disease 1
• Avoid prolonged high-dose therapy (>30 mg/day) due to increased risk of adverse effects 1

In summary, your patient on long-term steroids for PMR should be referred to a rheumatologist for assessment and management of steroid discontinuation, as this requires specialist expertise to balance the risks of disease relapse against the complications of continued steroid therapy.