Initial Treatment for Polymyalgia Rheumatica (PMR)

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

Glucocorticoid Therapy Principles

Glucocorticoids (GCs) are strongly recommended as first-line therapy over NSAIDs for PMR treatment 1, 2
The initial dose should be individualized within the 12.5-25 mg/day range based on:
- Higher doses (closer to 25 mg) for patients with high relapse risk and low adverse event risk 2
- Lower doses (closer to 12.5 mg) for patients with relevant comorbidities (diabetes, osteoporosis, glaucoma) 2
Initial doses ≤7.5 mg/day are discouraged, and doses >30 mg/day are strongly recommended against 1, 2
Single morning doses are preferred over divided daily doses, except in cases of prominent night pain when tapering below 5 mg daily 1, 2

Initial tapering: Reduce dose to 10 mg/day prednisone equivalent within 4-8 weeks 1, 2
Once remission is achieved: Taper daily 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

Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1, 2
Early introduction of methotrexate (MTX) should be considered in addition to GCs for patients with:
- High risk for relapse or prolonged therapy 1, 2
- Risk factors for GC-related adverse events 1, 2
- MTX has been used at oral doses of 7.5-10 mg/week in clinical trials 1, 2

Follow-up visits are recommended every 4-8 weeks during the first year of treatment 1, 2
Regular monitoring should include:
- Disease activity assessment 1
- Laboratory markers (ESR, CRP) 1, 2
- Evaluation for GC-related adverse effects 1, 2
- Assessment of comorbidities and risk factors for relapse 1

TNFα blocking agents are strongly recommended against for PMR treatment 1, 2
NSAIDs should not be used as primary therapy, though short-term use may be considered for pain related to other conditions 1

For relapse: Increase prednisone to the pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 4, 2
After re-establishing control, reduce more slowly than initially 4, 2
For patients with multiple relapses, consider adding methotrexate as a corticosteroid-sparing agent 4, 2

Starting with too low a dose (<7.5 mg/day) may lead to inadequate symptom control 1, 2
Starting with too high a dose (>30 mg/day) increases risk of adverse effects without additional benefit 1, 2
Tapering too quickly can lead to more frequent relapses 3
Failure to monitor for GC-related adverse effects can lead to significant morbidity 1, 2
Not considering methotrexate early in patients at high risk for relapse or GC-related adverse events 1, 2