Initial Treatment for Polymyalgia Rheumatica
The initial treatment for polymyalgia rheumatica (PMR) should be prednisone 12.5-25 mg daily as first-line therapy. 1
Glucocorticoid Initial Dosing
- The European League Against Rheumatism recommends starting with prednisone 12.5-25 mg daily for patients with newly diagnosed PMR 1
- Higher initial doses within this range (closer to 25 mg) are appropriate for patients with high risk of relapse and low risk of adverse events 1
- 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 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
Glucocorticoid Tapering Schedule
- After initiating treatment, reduce the dose to 10 mg/day prednisone equivalent within 4-8 weeks 1
- Once remission is achieved, taper prednisone by 1 mg every 4 weeks (or using alternate-day schedules like 10/7.5 mg) until discontinuation 1
- Most patients respond dramatically to glucocorticoid therapy within days of starting treatment 2
- For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1
Steroid-Sparing Agents
- Methotrexate (7.5-10 mg weekly) should be considered as an adjunctive therapy in patients at high risk for relapse or prolonged therapy 1
- Methotrexate has been shown to reduce the cumulative prednisone dose and increase the proportion of patients able to discontinue prednisone 3
- Consider methotrexate for patients with risk factors for glucocorticoid-related adverse events or those who have experienced a relapse without significant response to glucocorticoids 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 4, 1
- After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 4
- For patients who relapse on 5 mg or less of prednisone, return to the previous dose that effectively controlled symptoms 4
Monitoring and Follow-up
- Regular monitoring of disease activity, laboratory markers (ESR, CRP), and adverse events is essential for individualizing treatment 1
- Follow-up visits are recommended every 4-8 weeks during the first year of treatment 4, 1
- Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density 1
Common Pitfalls and Caveats
- Relapses are common when the prednisone dose is reduced to 5 mg/day or lower 5
- Treatment duration varies significantly between patients, with most requiring 1-2 years of therapy, though some may need up to 4 years 2, 6
- Failure to respond to an adequate dose of prednisone (15-20 mg/day) within 7 days should prompt reconsideration of the diagnosis 5
- TNFα blocking agents and Chinese herbal preparations Yanghe and Biqi capsules should be avoided in PMR treatment 1
- Osteoporosis prophylaxis should be considered for patients on long-term glucocorticoid therapy 5