What are the essential practices for managing polymyalgia rheumatica?

Essential Practices for Managing Polymyalgia Rheumatica

Glucocorticoid therapy is the cornerstone of polymyalgia rheumatica (PMR) management, with an initial recommended dose of 12.5-25 mg prednisone equivalent daily, individualized based on patient risk factors for relapse and adverse effects. 1, 2

Initial Assessment and Diagnosis

• Consider specialist referral for atypical presentations (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years), high risk of therapy-related side effects, or PMR refractory to glucocorticoid therapy 1
• Determine comorbidities that may affect treatment decisions, particularly hypertension, diabetes, osteoporosis, glaucoma, cardiovascular disease, and peptic ulcer 1
• Assess risk factors for relapse/prolonged therapy, including female sex, high ESR (>40 mm/hr), and peripheral inflammatory arthritis 1

Glucocorticoid Treatment Protocol

• Use glucocorticoids as first-line therapy rather than NSAIDs for PMR treatment 1, 2
• Select initial prednisone dose within 12.5-25 mg/day range:
  • 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 2
  • Avoid initial doses ≤7.5 mg/day (conditionally discouraged) and >30 mg/day (strongly discouraged) 1, 2
• Consider intramuscular methylprednisolone as an alternative to oral glucocorticoids 1, 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 prednisone by 1 mg every 4 weeks (or using alternate-day schedules) until discontinuation 1, 2
• Slow tapering (<1 mg/month) is associated with fewer relapses and more frequent treatment cessation 3

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, 2
• After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 4
• For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose 4, 2

Steroid-Sparing Agents

• Consider methotrexate (7.5-10 mg weekly) as adjunctive therapy for:
  • Patients at high risk for relapse or prolonged therapy 2, 5
  • Patients with risk factors for glucocorticoid-related adverse events 2
  • Patients who have experienced a relapse without significant response to glucocorticoids 2
• Methotrexate has demonstrated efficacy at doses of 10 mg/week or higher 3, 5
• Avoid TNFα blocking agents (such as infliximab) for PMR treatment 2, 6

Monitoring and Follow-up

• Schedule follow-up visits every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as indicated for relapses or during tapering 1, 2
• Monitor for:
  • Steroid-related side effects
  • Disease activity and inflammatory markers (ESR, CRP)
  • Comorbidities and risk factors for relapse 1
• Ensure patients have rapid access to healthcare providers to report flares and adverse events 1

Patient Education and Support

• Provide education about PMR impact, treatment effects, comorbidities, and disease predictors 1
• Advise on individually tailored exercise programs 1
• Create an individualized PMR management plan with shared decision-making between patient and physician 1

Bone Health Management

• Systematically evaluate bone mineral density as prednisone can cause significant bone loss 2, 7
• Consider osteoporosis prophylaxis for patients on long-term glucocorticoid therapy 8