From the Guidelines
Corticosteroids, specifically prednisone, are the primary treatment for polymyalgia rheumatica (PMR), with a typical starting dose of 12.5-25 mg daily, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1. The treatment approach for PMR involves several key considerations, including:
- Initial dose: The panel conditionally recommends using the minimum effective GC dose within a range of 12.5–25 mg prednisone equivalent daily as the initial treatment of PMR 1.
- Tapering schedule: The panel strongly recommends individualising dose tapering schedules, predicated to regular monitoring of patient disease activity, laboratory markers and adverse events, with a suggested tapering schedule of reducing the dose by 1 mg every 4 weeks once remission is achieved 1.
- Steroid-sparing agents: Methotrexate may be considered as a steroid-sparing agent, particularly in patients at a high risk for relapse and/or prolonged therapy, with a typical dose of 7.5–10 mg/week 1.
- Monitoring: Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential, with follow-up every 4–8 weeks in the first year, every 8–12 weeks in the second year, and as indicated in case of relapse or as prednisone is tapered off 1.
- Prevention of bone loss: Patients should take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements to prevent bone loss, and may need a proton pump inhibitor to protect the stomach 1. Some key points to consider when treating PMR include:
- The importance of assessing comorbidities, other relevant medications, and possible risk factors for steroid-related side effects and relapse/prolonged therapy 1.
- The use of intramuscular methylprednisolone as an alternative to oral GCs, with a starting dose of 120 mg every 3 weeks 1.
- The consideration of an individualised exercise programme for PMR patients aimed at the maintenance of muscle mass and function, and reducing risk of falls especially in older persons on long-term GCs as well as in frail patients 1.
From the Research
Treatment Overview
The treatment for Polymyalgia Rheumatica (PMR) typically involves the use of corticosteroids, such as prednisone or prednisolone, to control symptoms and suppress inflammation 2, 3, 4.
Initial Treatment
- The initial dose of prednisone or prednisolone can range from 12.5 to 25 mg/day, with some studies suggesting a starting dose of 15 mg/day 2, 3, 4.
- The dose is then tapered down to a maintenance dose, typically around 7.5 mg/day, over a period of several weeks or months 2, 3, 4.
Alternative Therapies
- For patients who experience side effects or relapses with traditional corticosteroid therapy, alternative treatments such as methotrexate, leflunomide, or biologic agents like tocilizumab and sarilumab may be considered 3, 5, 6.
- These therapies can help reduce the dose of corticosteroids needed and minimize the risk of relapse 3, 5, 6.
Steroid-Sparing Agents
- Methotrexate has been shown to be effective as a steroid-sparing agent in PMR, allowing for a reduction in the dose of prednisone needed to control symptoms 5.
- Other biologic agents, such as tocilizumab, have also demonstrated efficacy in reducing relapse frequency and cumulative glucocorticoid burden in PMR patients 3, 6.
Treatment Duration
- The duration of treatment for PMR can vary, but most patients can be tapered off corticosteroids within 1-2 years of starting treatment 2, 4.
- Some patients may require longer-term treatment, and the use of alternative therapies can help minimize the risk of relapse and reduce the dose of corticosteroids needed 3, 5, 6.