What are the treatment criteria for polymyalgia rheumatica?

Treatment Criteria for Polymyalgia Rheumatica

The recommended initial treatment for polymyalgia rheumatica (PMR) is glucocorticoid therapy at a dose of 12.5-25 mg prednisone equivalent daily, with subsequent individualized tapering over 1-2 years based on clinical response and risk factors. 1, 2

Initial Treatment Approach

Glucocorticoid Therapy

• Initial prednisone dose: 12.5-25 mg/day
  • Higher initial doses within this range for patients with high relapse risk and low adverse event risk
  • Lower initial doses for patients with relevant comorbidities (diabetes, osteoporosis, glaucoma)
  • Doses ≤7.5 mg/day are conditionally discouraged
  • Doses >30 mg/day are strongly discouraged 2, 1

Administration

• Single daily doses are preferred
• Divided doses may be considered for prominent night pain when tapering below 5 mg daily
• Alternative: Intramuscular methylprednisolone (120 mg every 3 weeks) may be considered 1

Tapering Schedule

1. Taper to 10 mg/day within 4-8 weeks of starting treatment
2. Once remission is achieved, taper prednisone by 1 mg every 4 weeks
3. Alternate-day schedules (e.g., 10/7.5 mg) may be used during tapering
4. Total treatment duration should be at least 1-2 years 1

Management of Relapses

• If relapse occurs, increase prednisone to the pre-relapse dose
• Gradually decrease (within 4-8 weeks) to the dose at which relapse occurred 1

Adjunctive Therapy

• Methotrexate (7.5-10 mg/week orally) is conditionally recommended for:
  • Patients at high risk for relapse
  • Those requiring prolonged therapy
  • Patients with risk factors for glucocorticoid-related adverse events 1, 3
• TNFα blocking agents are strongly discouraged 1
• NSAIDs are not recommended as primary treatment (except for short-term use for pain related to other conditions) 2, 1

Monitoring Requirements

1. Regular assessment of:

   • Disease activity
   • Laboratory markers (ESR, CRP)
   • Glucocorticoid-related side effects
   • Comorbidities
   • Other relevant medications 2

2. Follow-up schedule:

   • Every 4-8 weeks in the first year
   • Every 8-12 weeks in the second year
   • As indicated for relapses or during tapering 2

Risk Stratification

PMR patients can be stratified into different treatment requirement groups based on:

• Initial ESR levels
• Response to therapy
• Interleukin-6 levels 4

Special Considerations

• Specialist referral should be considered for:
  • Atypical presentation (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years)
  • High risk of therapy-related side effects
  • PMR refractory to glucocorticoid therapy
  • Relapses or need for prolonged therapy 2, 1

Patient Education and Support

• Patients should have an individualized PMR management plan
• Education should focus on disease impact, treatment effects, comorbidities
• Individualized exercise programs are recommended to maintain muscle mass and function
• Patients should have rapid access to healthcare providers to report flares and adverse events 2, 1

Common Pitfalls and Caveats

• Failure to exclude mimicking conditions before initiating treatment
• Inadequate initial dosing leading to poor symptom control
• Overly rapid tapering increasing relapse risk
• Neglecting to monitor for and manage glucocorticoid-related adverse effects
• Not considering steroid-sparing agents in high-risk patients or those with frequent relapses
• Mortality is significantly higher in patients treated with high doses of systemic corticosteroids (>40 mg daily) 1