What is the typical treatment for polymyalgia rheumatica?

Polymyalgia Rheumatica Treatment

The standard treatment for polymyalgia rheumatica (PMR) is oral prednisone at an initial dose of 12.5-25 mg daily, followed by a gradual tapering schedule once remission is achieved. 1

Initial Glucocorticoid Therapy

• Start with oral prednisone 12.5-25 mg daily as first-line therapy 2, 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
• Clinical improvement should be observed within 2-4 weeks of starting treatment 2
• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids in select patients, particularly when a lower cumulative glucocorticoid dose is desirable 2, 1

Glucocorticoid Tapering Schedule

• Reduce the dose to 10 mg/day prednisone equivalent within 4-8 weeks of starting treatment 1
• Once remission is achieved, taper prednisone by 1 mg every 4 weeks (or use alternate-day schedules) until discontinuation 1
• Slow prednisone dose tapering (<1 mg/month) is associated with fewer relapses and more frequent treatment cessation than faster tapering regimens 3
• 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 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 symptom control, reduce more slowly than initially, not exceeding 1 mg per month 4, 1
• For patients who relapse on 5 mg or less of prednisone, return to the previous effective dose 4

Steroid-Sparing Agents

• Methotrexate (7.5-10 mg weekly) should be considered as adjunctive therapy in: 1
  • Patients at high risk for relapse or prolonged therapy
  • Patients with risk factors for glucocorticoid-related adverse events
  • Patients who have experienced a relapse without significant response to glucocorticoids
  • Patients experiencing glucocorticoid-related adverse events
• Methotrexate has shown efficacy at doses of 10 mg/week or higher 3
• TNFα blocking agents (such as infliximab) are strongly recommended against for PMR treatment 1

Monitoring and Follow-up

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

Important Considerations

• PMR is a heterogeneous disease with variations in treatment duration and glucocorticoid dose requirements 5
• Starting prednisone doses higher than 10 mg/day are associated with fewer relapses but may lead to more glucocorticoid-related adverse effects 3
• Modified-release prednisone taken at bedtime may offer advantages in controlling inflammation, particularly IL-6 levels 6
• Osteoporosis prophylaxis is recommended for patients on long-term glucocorticoid therapy 7
• Most patients with PMR require treatment for 1-2 years, though some may need longer therapy 8