Recommended Medications for Polymyalgia Rheumatica (PMR) Treatment
Glucocorticoids are the cornerstone of PMR treatment, with an initial prednisone dose of 12.5-25 mg daily recommended, followed by a structured tapering schedule, and methotrexate should be considered as a steroid-sparing agent in patients with relapsing disease or at high risk for glucocorticoid-related adverse effects. 1
Initial Glucocorticoid Therapy
- Start with prednisone 12.5-25 mg daily (single morning dose) as first-line therapy 1
- Higher initial doses within this range (closer to 25 mg) may be appropriate for patients with high risk of relapse and low risk of adverse events 1
- Lower initial doses within this range (closer to 12.5 mg) should be used for patients with relevant comorbidities (diabetes, osteoporosis, glaucoma) 1
- Initial doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly recommended against 1
- Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1
Glucocorticoid Tapering Schedule
- Initial tapering: Reduce dose to 10 mg/day prednisone equivalent within 4-8 weeks 1
- Once remission is achieved: Taper prednisone by 1 mg every 4 weeks (or using alternate-day schedules like 10/7.5 mg) until discontinuation 1, 2
- Slow tapering (<1 mg/month) is associated with fewer relapses and more frequent treatment cessation 3
Management of Relapses
- For relapse: Increase prednisone to the pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 1, 2
- After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 2
- For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1, 2
Steroid-Sparing Agents
- Methotrexate (7.5-10 mg weekly) should be considered as an adjunctive therapy in: 1, 4
- Patients at high risk for relapse or prolonged therapy
- Patients with risk factors for glucocorticoid-related adverse events
- Patients who have experienced a relapse without significant response to glucocorticoids
- Patients experiencing glucocorticoid-related adverse events
- Methotrexate has demonstrated efficacy at doses of 10 mg/week or higher, allowing for reduced cumulative prednisone exposure 3, 4, 5
Medications to Avoid
- TNFα blocking agents (such as infliximab) are strongly recommended against for PMR treatment 1
- Chinese herbal preparations Yanghe and Biqi capsules are strongly recommended against 1
Monitoring and Follow-up
- Regular monitoring of disease activity, laboratory markers (ESR, CRP), and adverse events is essential for individualizing treatment 1, 2
- Follow-up visits every 4-8 weeks during the first year of treatment are recommended 2
- Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density, as prednisone can cause significant bone loss 2, 5
Emerging Therapies
- Recent evidence suggests tocilizumab and sarilumab may have potential as steroid-sparing agents, though these are not yet included in formal guidelines 6