What is the recommended treatment for polymyalgia rheumatica?

Treatment of Polymyalgia Rheumatica

Start prednisone at 12.5-25 mg daily as first-line therapy, with most patients responding well to 15 mg/day, then taper to 10 mg/day within 4-8 weeks, followed by gradual reduction of 1 mg every 4 weeks until discontinuation. 1

Initial Glucocorticoid Dosing

The European League Against Rheumatism establishes a dosing range of 12.5-25 mg daily of prednisone, with the specific dose determined by patient risk factors 1:

• Use higher doses (closer to 25 mg) for patients at high risk of relapse and low risk of adverse events 1
• Use lower doses (closer to 12.5 mg) for patients with relevant comorbidities including diabetes, osteoporosis, or glaucoma 1
• Avoid initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect 1
• Strongly avoid doses >30 mg/day due to increased adverse effects without additional benefit 1

Research supports that starting doses of 15 mg/day achieve clinical improvement in the majority of patients within 7 days, with this dose providing an optimal balance between efficacy and cumulative steroid exposure 2, 3. Higher starting doses (>15 mg/day) are associated with more glucocorticoid-related adverse effects without clear benefit 2.

Alternative route: Intramuscular methylprednisolone 120 mg every 3 weeks can be considered as an alternative to oral glucocorticoids 1.

Tapering Schedule

The European League Against Rheumatism recommends a structured tapering approach 1:

• Reduce to 10 mg/day within 4-8 weeks after initiating therapy 1
• Once remission is achieved, taper by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg on alternating days) until discontinuation 1
• Slow tapering (<1 mg/month) below 10 mg/day is associated with fewer relapses and more frequent successful treatment cessation compared to faster tapering 2

A common pitfall is tapering too quickly below 10 mg/day, which significantly increases relapse risk. The evidence consistently shows that reductions exceeding 1 mg per month at lower doses lead to more frequent disease flares 4, 2.

Management of Relapses

For patients who relapse during tapering 4, 1:

• If relapsing on ≤5 mg/day: Return to the previous dose that effectively controlled symptoms 4
• For all relapses: Increase prednisone to the pre-relapse dose, then gradually reduce over 4-8 weeks back 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, 1
• For persistent nighttime pain when tapering below 5 mg/day: Consider splitting the daily dose rather than using a single morning dose 4, 1

Steroid-Sparing Therapy with Methotrexate

Consider adding methotrexate 7.5-10 mg weekly in the following situations 1:

• Patients at high risk for relapse or requiring prolonged therapy 1
• Patients with risk factors for glucocorticoid-related adverse events 1
• Patients who have experienced a relapse without significant response to glucocorticoids 1
• Patients experiencing glucocorticoid-related adverse events 1
• Patients with multiple or prolonged relapses 4

The evidence for methotrexate is robust: a randomized controlled trial demonstrated that 88% of patients receiving prednisone plus methotrexate were able to discontinue prednisone by 76 weeks compared to only 53% receiving prednisone alone, with significantly fewer flare-ups (47% vs 73%) and lower cumulative prednisone doses (2.1 g vs 2.97 g) 5. Methotrexate at doses of 10 mg/week or higher provides meaningful glucocorticoid-sparing effects 2.

Important: Provide folinic acid supplementation (7.5 mg weekly) when prescribing methotrexate 5.

Medications to Avoid

The European League Against Rheumatism strongly recommends against 1:

• TNFα blocking agents (such as infliximab) - proven ineffective for PMR 1, 2
• Chinese herbal preparations (Yanghe and Biqi capsules) 1

Monitoring Protocol

Systematic monitoring is essential throughout treatment 1:

• Follow-up visits every 4-8 weeks during the first year of treatment 4, 1
• Monitor inflammatory markers (ESR and CRP) and clinical symptoms at each visit to assess treatment response 4
• Systematically evaluate for glucocorticoid-related adverse effects: bone mineral density, blood pressure, blood glucose, and ocular examinations 1
• Assess comorbidities and relapse risk factors at each visit 4

A critical caveat: PMR is heterogeneous, with some patients requiring treatment for less than 1 year while others need prolonged therapy beyond 2 years 6. Patients with persistently elevated interleukin-6 levels despite ESR normalization after 4 weeks of therapy may represent partial responders requiring longer treatment duration 6.