Initial Treatment for Polymyalgia Rheumatica (PMR)
The initial treatment for polymyalgia rheumatica is glucocorticoids (GCs), specifically prednisone at a dose of 12.5-25 mg daily. 1, 2
Glucocorticoid Therapy Recommendations
- Glucocorticoids are strongly recommended over NSAIDs as the first-line treatment for PMR 1
- The recommended initial dose range is 12.5-25 mg prednisone equivalent daily 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 relevant 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
- Single daily dosing is preferred over divided doses, except in cases of prominent night pain when tapering below 5 mg daily 1, 3
Alternative Initial Treatment Options
- Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1, 2
- This option may be particularly useful for patients at high risk of glucocorticoid-related adverse effects 2
Tapering Schedule
- Initial tapering: Reduce 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 like 10/7.5 mg) until discontinuation 1, 2
- Slow prednisone dose tapering (<1 mg/month) is associated with fewer relapses and more frequent glucocorticoid treatment cessation 4
Steroid-Sparing Agents
- 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
- Relapse without significant response to glucocorticoids
- Methotrexate has demonstrated efficacy as a steroid-sparing agent at doses of 10 mg/week or higher 5, 4
Monitoring and Follow-up
- Follow-up visits are recommended every 4-8 weeks during the first year of treatment 1, 2
- Monitor for:
- Disease activity and clinical symptoms
- Laboratory markers (ESR, CRP)
- Glucocorticoid-related adverse effects
- Risk factors for relapse 1
Medications to Avoid
- TNFα blocking agents (such as infliximab) are strongly recommended against for PMR treatment 1, 2
- Long-term use of NSAIDs is not recommended, though short-term use may be considered for pain related to other conditions 1
Common Pitfalls and Caveats
- Failure to respond to moderate-dose prednisone (15-20 mg/day) within 7 days should prompt consideration of alternative diagnoses 6
- Relapses are common when prednisone dose is reduced to 5 mg/day or lower 6
- Osteoporosis prophylaxis should be considered for patients on long-term glucocorticoid therapy 6, 7
- Patients with atypical presentations or inadequate response to therapy should be referred to specialists for further evaluation 1, 7