Recommended Treatment for Polymyalgia Rheumatica (PMR)
The first-line treatment for polymyalgia rheumatica is oral prednisone at an initial dose of 12.5-25 mg daily, followed by a structured tapering schedule. 1
Initial Glucocorticoid Therapy
- Prednisone is the cornerstone of PMR treatment, with recommended starting doses between 12.5-25 mg daily 1, 2
- 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
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 use alternate-day schedules) 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 prednisone to the pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 3, 1
- After re-establishing control, reduce more slowly than initially, not exceeding 1 mg per month 3
- For patients who relapse on 5 mg or less of prednisone, return to the previous dose that effectively controlled symptoms 3
Steroid-Sparing Agents
- Methotrexate (7.5-10 mg weekly) should be considered as an adjunctive therapy in the following situations: 1
- Patients at high risk for relapse or prolonged therapy
- Patients with risk factors for glucocorticoid-related adverse events
- Patients who have experienced multiple or prolonged relapses 3
- Patients experiencing glucocorticoid-related adverse events
Monitoring and Follow-up
- Schedule follow-up visits every 4-8 weeks during the first year of treatment 3, 2
- Closely monitor inflammatory markers (ESR, CRP) and clinical symptoms to assess treatment response 3
- Systematically evaluate for glucocorticoid-related adverse effects, comorbidities, and relapse risk factors 3, 2
Risk Factors to Consider
- Risk factors for relapse/prolonged therapy include female sex, high ESR (>40 mm/hr), and peripheral inflammatory arthritis 2
- Comorbidities that may affect treatment decisions include hypertension, diabetes, osteoporosis, glaucoma, cardiovascular disease, and peptic ulcer 2
Treatment Pitfalls and Caveats
- PMR is a heterogeneous disease with variations in treatment duration and corticosteroid requirements 4
- Patients typically respond to appropriate prednisone dosing within 7 days; consider alternative diagnoses if no response occurs with 20 mg/day 5
- Relapses are common when prednisone dose is reduced to 5 mg/day or lower 5
- TNFα blocking agents and Chinese herbal preparations (Yanghe and Biqi capsules) should be avoided in PMR treatment 1
- Osteoporosis prophylaxis is recommended for patients on long-term glucocorticoid therapy 5