What is the recommended treatment for polymyalgia rheumatica?

Treatment of Polymyalgia Rheumatica

The recommended first-line treatment for polymyalgia rheumatica (PMR) is prednisone at an initial dose of 12.5-25 mg daily, with subsequent tapering based on symptom control and individual risk factors. 1

Initial Glucocorticoid Therapy

• Start with prednisone 12.5-25 mg daily as the cornerstone of PMR treatment 1
• Higher initial doses (closer to 25 mg) are appropriate for patients with high risk of relapse and low risk of adverse events 1
• Lower initial doses (closer to 12.5 mg) should be used for patients with relevant comorbidities such as diabetes, osteoporosis, or 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

• Reduce the prednisone dose to 10 mg/day within 4-8 weeks after initiating treatment 1
• Once remission is achieved, taper prednisone by 1 mg every 4 weeks (or use alternate-day schedules) until discontinuation 1
• Slow tapering (<1 mg/month) is associated with fewer relapses and more successful glucocorticoid discontinuation compared to faster tapering regimens 2
• For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1

Management of Relapses

• For patients experiencing a relapse, increase prednisone to the pre-relapse dose and then decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 3, 1
• For patients who relapse on 5 mg or less of prednisone, return to the previous effective dose that controlled symptoms 3
• After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 3
• Close monitoring of inflammatory markers (ESR, CRP) and clinical symptoms is essential to assess treatment response 3

Steroid-Sparing Agents

• Methotrexate (7.5-10 mg weekly) should be considered as an adjunctive therapy in the following situations: 1
  • Patients at high risk for relapse or requiring prolonged therapy 1
  • Patients with risk factors for glucocorticoid-related adverse events 1
  • Patients who have experienced multiple or prolonged relapses 3
  • Patients experiencing glucocorticoid-related adverse events 1
• Methotrexate at doses of 10 mg/week or higher has demonstrated efficacy as a steroid-sparing agent 4, 2
• A randomized controlled trial showed that patients receiving methotrexate were more likely to discontinue prednisone by 76 weeks compared to those receiving placebo (87.5% vs 53.3%) 4

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 not recommended 1

Monitoring and Follow-up

• Regular follow-up visits every 4-8 weeks during the first year of treatment are recommended 3, 1
• Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density 1
• Monitor inflammatory markers (ESR, CRP) to assess disease activity and treatment response 3, 5

Special Considerations

• PMR appears to be a heterogeneous disease with variations in treatment duration and corticosteroid requirements 5
• Patients with lower initial ESR values may require shorter treatment courses with fewer relapses 5
• Persistent elevation of interleukin-6 levels after 4 weeks of therapy may indicate a subset of patients with partial response requiring more aggressive treatment 5