From the Guidelines
The first-line treatment for Polymyalgia Rheumatica (PMR) is glucocorticoids (GCs), specifically prednisone, at a dose of 12.5-25 mg per day.
Key Considerations
- The dose of prednisone should be individualized based on the patient's risk of relapse and adverse events, with a higher dose considered in patients with a high risk of relapse and low risk of adverse events, and a lower dose in patients with relevant comorbidities and other risk factors for GC-related side effects 1, 2, 3, 4.
- The panel conditionally recommends using the minimum effective GC dose within a range of 12.5–25 mg prednisone equivalent daily as the initial treatment of PMR 4.
- Methotrexate (MTX) may be considered as an addition to GCs, particularly in patients at a high risk for relapse and/or prolonged therapy, as well as in cases with risk factors, comorbidities, and/or concomitant medications where GC-related adverse events are more likely to occur 2, 3.
Treatment Approach
- Initial tapering: Taper dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks 2, 4.
- Relapse therapy: Increase oral prednisone to the pre-relapse dose and decrease it gradually (within 4–8 weeks) to the dose at which the relapse occurred 2, 4.
- Tapering once remission is achieved: Taper daily oral prednisone by 1 mg every 4 weeks (or by 1.25 mg decrements using schedules such as 10/7.5 mg alternate days, etc) until discontinuation given that remission is maintained 2, 3, 4.
From the Research
First-Line Treatment for Polymyalgia Rheumatica (PMR)
- The primary treatment of choice for PMR is corticosteroids, specifically low-dose glucocorticoids 5, 6, 7.
- Glucocorticoid therapy is effective in PMR, with most patients responding promptly to 15-25 mg prednisolone per day 6.
- However, one study suggests that ibuprofen could be considered as a first-line nonsteroidal anti-inflammatory drug for PMR, particularly in elderly patients who are susceptible to the condition and may need to avoid corticosteroids 8.
- The use of glucocorticoid-sparing agents, such as methotrexate, has also been explored, with some studies indicating a modest benefit in clinical trials 5, 9, 7.
Treatment Considerations
- The optimal glucocorticoid type, starting doses, and subsequent reduction regimens may vary depending on the individual patient and the disease severity 5.
- Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 5.
- The addition of oral or intramuscular methotrexate may provide efficacy at doses of 10 mg/wk or higher, although more research is needed to confirm its effectiveness as a glucocorticoid-sparing agent 5, 9, 7.