What is the initial treatment for a patient presenting with Polymyalgia Rheumatica (PMR) peripheral symptoms?

Initial Treatment for Polymyalgia Rheumatica (PMR) with Peripheral Symptoms

The initial treatment for polymyalgia rheumatica (PMR) with peripheral symptoms is oral glucocorticoids at a dose of 12.5-25 mg prednisone equivalent daily. 1, 2

Glucocorticoid Therapy Recommendations

• The European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) strongly recommend glucocorticoids as first-line therapy rather than NSAIDs for patients with PMR 1
• The recommended initial dose range is 12.5-25 mg prednisone equivalent daily, with dose selection based on individual patient factors 2
• 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 2
• Lower initial doses within this range (closer to 12.5 mg) should be used for patients with comorbidities such as diabetes, osteoporosis, or glaucoma 2
• Initial doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly recommended against 1, 2

Peripheral Symptoms Considerations

• Peripheral inflammatory arthritis has been identified as a risk factor for relapse and/or prolonged therapy in some studies, which may influence initial dosing decisions 1
• Patients with peripheral symptoms may require closer monitoring as they may be at higher risk for relapse 1
• Consider specialist referral for patients with atypical presentation such as peripheral inflammatory arthritis 1

Tapering Schedule

• After initiating treatment, taper the dose to 10 mg/day prednisone equivalent within 4-8 weeks 1, 2
• Once remission is achieved, taper daily oral prednisone by 1 mg every 4 weeks (or by using alternate-day schedules) until discontinuation 1, 2
• Individualize tapering schedules based on regular monitoring of disease activity, laboratory markers, and adverse events 1

Alternative and Adjunctive Treatments

• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1, 2
• Consider early introduction of methotrexate (7.5-10 mg weekly) in addition to glucocorticoids for patients with: 1, 2
  • High risk for relapse or prolonged therapy
  • Risk factors for glucocorticoid-related adverse events
  • Peripheral inflammatory arthritis (which may predict more difficult disease course) 1, 3
• Single daily dosing of glucocorticoids is generally preferred, except for cases with prominent night pain when tapering below 5 mg daily 1, 2

Monitoring and Follow-up

• Follow-up visits should be scheduled every 4-8 weeks in the first year of treatment 1, 2
• Monitor inflammatory markers (ESR, CRP), clinical symptoms, and potential glucocorticoid-related adverse effects 4, 2
• Systematically evaluate for risk factors and evidence of steroid-related side effects, comorbidities, and risk factors for relapse 1, 4

Management of Relapses

• If relapse occurs, increase prednisone to the pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 1, 4
• After re-establishing control, reduce more slowly than initially 4
• For patients with multiple relapses, consider adding methotrexate as a corticosteroid-sparing agent 4, 3

Important Cautions

• TNFα blocking agents are strongly recommended against for PMR treatment 1, 2
• Patients with atypical presentations or who fail to respond to standard glucocorticoid doses should be referred to specialists to rule out mimicking conditions 1, 3
• Patients should have rapid access to medical advice if they experience flares or adverse events 1