What is the initial treatment for Polymyalgia Rheumatica (PMR)?

Initial Treatment for Polymyalgia Rheumatica (PMR)

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

Glucocorticoid Initial Dosing

• The European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) strongly recommend glucocorticoids (GCs) as the first-line therapy for PMR, rather than NSAIDs 2
• Initial prednisone dosing should be individualized within the 12.5-25 mg daily range based on:
  • Higher doses (closer to 25 mg) for patients with high relapse risk and low adverse event risk 1
  • Lower doses (closer to 12.5 mg) for patients with 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 2, 1
• Clinical improvement typically occurs within 7 days of starting therapy 3

Alternative Initial Treatments

• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 2, 1
• Single daily dosing is preferred over divided doses, except in cases of prominent night pain when tapering below 5 mg daily 2, 1

Initial Tapering Schedule

• After starting treatment, taper the prednisone dose to 10 mg/day within 4-8 weeks 2, 1
• Once remission is achieved, further taper by 1 mg every 4 weeks (or using alternate-day schedules) until discontinuation 1

Steroid-Sparing Agents

• Consider early introduction of methotrexate (7.5-10 mg weekly) in addition to glucocorticoids for patients with:
  • High risk for relapse or prolonged therapy 2, 1
  • Risk factors for glucocorticoid-related adverse events 1
  • Inadequate response to glucocorticoids 1
• Methotrexate has been shown to reduce the cumulative prednisone dose and help preserve bone mineral density 4

Monitoring and Follow-up

• Regular monitoring of disease activity, laboratory markers (ESR, CRP), and adverse events is essential 2, 1
• Follow-up visits should occur every 4-8 weeks during the first year of treatment 2, 1
• Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density 1

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 5, 1
• After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 5
• Relapses are common when the prednisone dose is ≤5 mg/day 3

Common Pitfalls and Caveats

• Failure to respond to 20 mg/day of prednisone should prompt consideration of alternative diagnoses 3
• TNFα blocking agents should not be used for PMR treatment 2, 1
• Osteoporosis prophylaxis is recommended for patients on long-term glucocorticoid therapy 3
• Treatment duration varies significantly; while some patients can discontinue therapy within 2 years, others may require 4 years or more 6, 7
• Clinical symptoms rather than ESR alone should define relapse, though ESR is the most useful laboratory parameter 6