What is the first-line treatment for polymyalgia rheumatica?

First-Line Treatment for Polymyalgia Rheumatica

The first-line treatment for polymyalgia rheumatica (PMR) is oral glucocorticoid therapy with prednisone at an initial dose of 12.5-25 mg daily. 1

Initial Glucocorticoid Therapy

• The European League Against Rheumatism recommends starting with prednisone 12.5-25 mg daily as the cornerstone of PMR treatment 1
• Dosing should be tailored based on patient characteristics:
  • 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
• Very low initial doses (≤7.5 mg/day) are discouraged, while high doses (>30 mg/day) are strongly recommended against 1
• Patient weight is a significant factor in determining response to prednisone therapy, with a target dose of approximately 0.19 mg/kg being effective for most responders 2

Glucocorticoid Tapering Schedule

• After clinical response is achieved, reduce the dose to 10 mg/day prednisone equivalent within 4-8 weeks 1
• Once remission is established, taper prednisone by 1 mg every 4 weeks (or using alternate-day schedules) until discontinuation 1
• For patients experiencing nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1

Alternative Glucocorticoid Options

• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids in select patients 1
• Modified-release prednisone taken at bedtime (10 pm) may provide better suppression of inflammatory markers, particularly IL-6, compared to conventional morning dosing 3

Management of Relapses

• For patients who experience a relapse, increase prednisone to the pre-relapse dose and then decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 4, 1
• After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 4
• For patients with relapse on 5 mg or less of prednisone, return to the previous effective dose that controlled symptoms 4

Steroid-Sparing Agents

• Consider methotrexate (7.5-10 mg weekly) as an adjunctive therapy in the following scenarios:
  • 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 4
  • Patients experiencing glucocorticoid-related adverse events 1
• Methotrexate has been shown to reduce the cumulative prednisone dose and increase the proportion of patients able to discontinue prednisone therapy 5

Monitoring and Follow-up

• Regular monitoring of disease activity, laboratory markers (ESR, CRP), and adverse events is essential for individualizing treatment 1
• Follow-up visits should occur every 4-8 weeks during the first year of treatment 4, 1
• Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density 1

Common Pitfalls and Caveats

• Using inadequate initial doses (≤10 mg/day) may lead to higher relapse rates, with studies showing 65% of patients relapse on an initial dose of 10 mg/day 6
• Laboratory markers (ESR, CRP) alone are not reliable predictors of relapse and should not be the sole basis for treatment decisions 6
• TNFα blocking agents (such as infliximab) and Chinese herbal preparations (Yanghe and Biqi capsules) are strongly recommended against for PMR treatment 1
• PMR patients may develop giant cell arteritis during treatment, requiring prompt dose escalation when symptoms suggest this complication 6