What is the typical dosing of prednisolone (corticosteroid) for polymyalgia rheumatica (PMR)?

Prednisolone Dosing for Polymyalgia Rheumatica (PMR)

The recommended initial dose of prednisolone for polymyalgia rheumatica is 12.5-25 mg daily, with subsequent tapering to 10 mg/day within 4-8 weeks. 1

Initial Dosing Considerations

• Start with prednisolone 12.5-25 mg daily as first-line therapy for PMR patients 1
• 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
• Initial doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly recommended against 1
• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1

Tapering Schedule

• Reduce the dose to 10 mg/day prednisolone equivalent within 4-8 weeks of starting treatment 1
• Once remission is achieved, taper prednisolone by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg) until discontinuation 1
• For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1

Management of Relapses

• For relapse, increase prednisolone to the pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 2, 1
• After re-establishing symptom control, reduce more slowly than initially, with a decrease rate not exceeding 1 mg per month 2
• For patients who relapse on 5 mg or less of prednisolone, return to the previous dose that effectively controlled symptoms 2

Steroid-Sparing Agents

• Consider methotrexate (7.5-10 mg weekly) as an adjunctive therapy in patients at high risk for relapse, prolonged therapy, or with risk factors for glucocorticoid-related adverse events 1
• For patients with multiple or prolonged relapses, methotrexate should be considered as a corticosteroid-sparing agent 2, 1
• Higher doses of methotrexate (up to 25 mg/week) may be more effective but are still being studied 3
• Methotrexate has been shown to reduce the cumulative prednisolone dose and increase the proportion of patients able to discontinue steroids 4

Monitoring and Follow-up

• Regular follow-up visits are recommended every 4-8 weeks during the first year of treatment 2, 1
• Closely monitor inflammatory markers (ESR, CRP) and clinical symptoms to assess treatment response 2
• Systematically evaluate for glucocorticoid-related adverse effects, comorbidities, and relapse risk factors 2, 1

Common Pitfalls and Caveats

• Starting with too low a dose (≤10 mg/day) may lead to inadequate symptom control and higher relapse rates (65% of patients relapsed on an initial dose of 10 mg/day in one study) 5
• Tapering too quickly can lead to disease flares; a more gradual reduction schedule is essential for long-term success 2, 1
• Relying solely on inflammatory markers (ESR, CRP) to guide treatment decisions is not recommended, as they may not reliably predict relapse 5
• While glucocorticoids are effective, they can cause significant adverse effects in up to 65% of patients, highlighting the importance of appropriate dosing and consideration of steroid-sparing agents 3, 6