Treatment of Polymyalgia Rheumatica
Start prednisone at 12.5-25 mg daily as first-line therapy, with the specific dose within this range determined by individual risk factors for relapse versus adverse events. 1
Initial Glucocorticoid Therapy
The European League Against Rheumatism establishes prednisone 12.5-25 mg daily as the standard initial treatment for polymyalgia rheumatica. 1 This recommendation is based on balancing efficacy against steroid-related toxicity.
Dose Selection Strategy
- Use higher initial doses (closer to 25 mg) for patients at high risk of relapse and low risk of adverse events 1
- Use lower initial doses (closer to 12.5 mg) for patients with relevant comorbidities including diabetes, osteoporosis, or glaucoma 1
- Never use initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect 1
- Never exceed 30 mg/day as initial therapy due to unacceptable adverse event risk 1
Alternative Route
- Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids 1
Glucocorticoid Tapering Protocol
After initial symptom control, reduce prednisone to 10 mg/day within 4-8 weeks, then continue a structured taper. 1
Tapering Schedule
- Reduce to 10 mg/day within 4-8 weeks of starting therapy 1
- Once remission is achieved, taper by 1 mg every 4 weeks until discontinuation 1
- Alternatively, use alternate-day schedules (e.g., 10/7.5 mg every other day) during the taper 1
- Slow tapering from low initial doses minimizes relapse risk while balancing steroid exposure 2
Management of Relapses
For patients who relapse, increase prednisone to the pre-relapse dose, then taper more slowly than the initial reduction. 3, 1
Relapse Protocol
- If relapse occurs on ≤5 mg prednisone: Return to the previous dose that controlled symptoms 3
- After re-establishing control: Gradually reduce over 4-8 weeks to the dose at which relapse occurred 3, 1
- Subsequent tapering must not exceed 1 mg per month 3, 1
- For persistent nighttime pain when reducing below 5 mg/day, split the daily dose rather than using a single morning dose 3, 1
Steroid-Sparing Therapy
Add methotrexate 7.5-10 mg weekly for patients at high risk of relapse, those requiring prolonged therapy, or those experiencing glucocorticoid-related adverse events. 1
Indications for Methotrexate
- Patients with multiple or prolonged relapses 3
- Patients at high risk for relapse or prolonged therapy 1
- Patients with risk factors for glucocorticoid-related adverse events 1
- Patients experiencing glucocorticoid-related adverse events 1
- Patients with inadequate response to glucocorticoids alone 1
Methotrexate plus prednisone results in shorter prednisone treatment duration, fewer flare-ups, and lower cumulative steroid doses compared to prednisone alone (87.5% vs 53% off steroids at 76 weeks, p=0.003). 4
Agents to Avoid
- TNFα blocking agents (such as infliximab) are strongly contraindicated for polymyalgia rheumatica treatment 1
- Chinese herbal preparations (Yanghe and Biqi capsules) are strongly contraindicated 1
Monitoring Requirements
Schedule follow-up visits every 4-8 weeks during the first year of treatment. 3, 1
At Each Visit
- Monitor inflammatory markers (ESR and CRP) 3, 1
- Assess clinical symptoms and treatment response 3
- Systematically evaluate for glucocorticoid-related adverse effects 3, 1
- Assess bone mineral density, as prednisone causes significant bone loss 1
- Evaluate comorbidities and relapse risk factors 3
Clinical Pearls and Pitfalls
Polymyalgia rheumatica is heterogeneous—pretreatment ESR and pain scores help predict treatment duration. 5 Patients with low ESR may require steroids for less than 1 year, while those with elevated interleukin-6 that doesn't respond to initial therapy often need prolonged treatment. 5
Most patients require treatment for several years, with high relapse rates during tapering. 6 Individualization and close monitoring are critical, as there is significant variability in prednisone pharmacokinetics between patients. 2