What is the recommended treatment for polymyalgia rheumatica (PMR)?

Polymyalgia Rheumatica: Symptoms and Treatment

Prednisone at an initial dose of 12.5-25 mg/day is the recommended first-line treatment for polymyalgia rheumatica (PMR), with tapering to 10 mg/day within 4-8 weeks and subsequent gradual reduction over 1-2 years. 1

Symptoms of PMR

PMR is an inflammatory condition primarily affecting individuals over 50 years of age, characterized by:

• Bilateral pain and stiffness in the shoulders, neck, and hip girdle
• Morning stiffness lasting more than 45 minutes
• Elevated inflammatory markers (ESR and CRP)
• Rapid response to glucocorticoid therapy
• Fatigue, malaise, depression, weight loss, and low-grade fever may also occur

Treatment Algorithm

Initial Glucocorticoid Therapy

1. First-line treatment: Oral prednisone at 12.5-25 mg/day as a single daily dose 1

   • Higher initial doses (>30 mg/day) are strongly discouraged due to increased risk of adverse effects without additional benefit
   • Lower doses (<7.5 mg/day) are discouraged due to inadequate symptom control

2. Tapering schedule:

   • Reduce to 10 mg/day within 4-8 weeks of starting treatment
   • Once remission is achieved, taper by 1 mg every 4 weeks (or use alternate day schedules)
   • Total treatment duration should be at least 1-2 years 1

3. Alternative administration:

   • Intramuscular methylprednisolone may be considered in patients with difficult-to-control hypertension, diabetes, osteoporosis, or glaucoma 1
   • Note: Evidence for reduced side effects with intramuscular administration is limited

Steroid-Sparing Agents

Methotrexate should be considered in the following scenarios 1, 2, 3:

• Patients at high risk for steroid-related toxicity
• Frequent relapses during glucocorticoid tapering
• Requirement for prolonged steroid therapy

Methotrexate administration:

• Dosage: 10 mg weekly with folic acid supplementation (at least 5 mg per week) 1, 2
• Monitoring: Liver function tests, albumin, CBC, and creatinine every 1-1.5 months until stable dose, then every 1-3 months 1
• Contraindicated in pregnancy planning, pregnancy, and breastfeeding 1

Treatment Considerations

• NSAIDs: Not recommended as primary treatment for PMR 1
• Anti-TNFα agents: Strongly discouraged for PMR treatment 1, 3
• Newer biologics: Anti-IL-6 receptor agents (tocilizumab, sarilumab) have shown efficacy in reducing relapse frequency and glucocorticoid burden in recent studies 3

Monitoring and Follow-up

1. Disease activity monitoring:

   • Regular assessment of symptoms
   • Monitor inflammatory markers (ESR, CRP)
   • Interleukin-6 levels may help identify patients who might have partial response to therapy 4

2. Treatment response patterns:

   • Some patients respond rapidly and require corticosteroids for less than 1 year 4
   • Others respond initially but cannot tolerate dose reduction and require longer treatment 4
   • A subset may have only partial response to initial steroid regimen 4

3. Watch for complications:

   • Development of giant cell arteritis (GCA) - may require higher steroid doses 5
   • Steroid-related adverse effects
   • Disease relapse during tapering

Important Caveats

• Risk of relapse: Approximately 50% of patients experience relapse during steroid tapering 2, 4
• Specialist referral: Consider for atypical presentation, high risk of therapy-related side effects, or refractory disease 1
• Patient education: Crucial for treatment adherence and monitoring for complications 1
• Individualized monitoring: Patients with higher initial pain scores and persistently elevated IL-6 levels may require more aggressive or prolonged therapy 4