From the Guidelines
Polymyalgia rheumatica (PMR) is best treated with oral corticosteroids, specifically prednisone at an initial dose of 12.5-25 mg daily, as recommended by the European League Against Rheumatism and American College of Rheumatology collaborative initiative 1.
Diagnosis and Treatment
The diagnosis of PMR is based on clinical presentation, laboratory markers, and exclusion of other conditions. The treatment goals are to reduce inflammation, alleviate symptoms, and prevent long-term complications.
Initial Treatment
- The initial dose of prednisone should be individualized, taking into account the patient's risk of relapse and adverse events, with a higher dose considered for patients with a high risk of relapse and a lower dose for those with comorbidities or risk factors for glucocorticoid-related side effects 1.
- The panel strongly recommends against the use of initial doses ≤7.5 mg/day and >30 mg/day 1.
Tapering Regimen
- The dose should be tapered gradually to a dose of 10 mg/day prednisone equivalent within 4-8 weeks, and then further tapered by 1 mg every 4 weeks until discontinuation, provided that remission is maintained 1.
- In case of relapse, the dose should be increased to the previously effective dose and then gradually tapered again 1.
Additional Recommendations
- Patients should be monitored regularly for symptoms, inflammatory markers, and potential steroid side effects 1.
- Calcium and vitamin D supplements are recommended to prevent steroid-induced osteoporosis 1.
- Gentle stretching exercises and acetaminophen for breakthrough pain may be considered for symptom management 1.
Prognostic Factors
- Female sex, high erythrocyte sedimentation rate, and peripheral arthritis may be associated with a higher relapse risk and longer duration of treatment 1.
From the Research
Diagnosis of Polymyalgia Rheumatica (PMR)
- The diagnosis of PMR is aided by clinical clues, laboratory tests, and imaging studies 2
- Typical symptoms include acute or subacute bilateral shoulder pain with severe stiffness and often neck and bilateral hip pain 2
- C-reactive protein and erythrocyte sedimentation rates are elevated in over 90% of patients 2
- Ultrasonography and magnetic resonance imaging (MRI) can be used to aid in diagnosis 2
Treatment of Polymyalgia Rheumatica (PMR)
- Glucocorticoids, such as prednisone, are the cornerstone therapy in the management of patients with PMR 3, 2
- An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR 3
- Methotrexate is the most commonly used corticosteroid sparing agent 3, 4, 5
- Methotrexate plus prednisone is associated with shorter prednisone treatment and steroid sparing 4, 5
- Treatment duration is typically 2-3 years but may be longer 2
- Under certain conditions, low-dose methotrexate can be used as adjuvant therapy 2
- Tocilizumab may be effective for GC-resistant patients 6
Management of Relapses and GC-Resistant PMR
- Relapses of PMR are not uncommon when the dose of prednisone is equal to or below 5 mg/day 3
- GC-resistant patients may require alternative therapies, such as methotrexate, salazosulfapyridine, or tocilizumab 6
- Baseline values of PMR activity score and its components, especially the ability to elevate the upper limbs (EUL), were significantly higher in GC-resistant patients compared with GC responders 6