Initial Treatment for Polymyalgia Rheumatica
Start with prednisone 12.5-25 mg daily as first-line therapy, with the specific dose within this range determined by the patient's comorbidity profile and relapse risk. 1
Determining the Initial Prednisone Dose
The European League Against Rheumatism provides clear guidance on dose selection within the 12.5-25 mg range:
- Use doses closer to 25 mg daily for patients with high relapse risk and low risk of adverse events 1
- Use doses closer to 12.5 mg daily for patients with relevant comorbidities including diabetes, osteoporosis, or glaucoma 1
- Never use initial doses ≤7.5 mg/day as these are discouraged due to insufficient anti-inflammatory effect 1
- Never exceed 30 mg/day as higher doses are strongly recommended against 1
This dosing strategy is supported by systematic review data showing that starting prednisone doses of 15 mg/day or lower are associated with lower cumulative glucocorticoid doses, while doses higher than 15 mg/day increase glucocorticoid-related adverse effects 2. However, doses higher than 10 mg/day are associated with fewer relapses and shorter therapy duration 2.
Alternative to Oral Therapy
- Intramuscular methylprednisolone 120 mg every 3 weeks can be considered as an alternative to oral glucocorticoids 1
Initial Tapering Schedule
Once symptoms are controlled with the initial dose:
- Reduce to 10 mg/day within 4-8 weeks 1
- After achieving remission, taper by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg) until discontinuation 1
- Tapering slower than 1 mg per month is associated with fewer relapses and more frequent successful glucocorticoid cessation 2
When to Add Methotrexate at Initial Presentation
Consider adding methotrexate 7.5-10 mg weekly from the outset in specific high-risk situations:
- Patients at high risk for relapse or anticipated prolonged therapy 1
- Patients with risk factors for glucocorticoid-related adverse events 1
- Patients with significant comorbidities where minimizing steroid exposure is critical 1
Research supports this approach, showing that initial addition of methotrexate at doses of 10 mg/week or higher provides steroid-sparing efficacy, with one trial demonstrating that 88% of patients receiving prednisone plus methotrexate were off prednisone at 76 weeks compared to 53% receiving prednisone alone 3, 2.
Monitoring Requirements
- Follow-up visits every 4-8 weeks during the first year 1
- Monitor inflammatory markers (ESR, CRP) and clinical symptoms at each visit 4
- Systematically evaluate for glucocorticoid-related adverse effects, particularly bone mineral density, as prednisone causes significant bone loss 1
Common Pitfalls to Avoid
- Do not use TNFα blocking agents (such as infliximab) as these are strongly recommended against for PMR treatment 1
- Do not use Chinese herbal preparations (Yanghe and Biqi capsules) as these are strongly recommended against 1
- Avoid starting doses that are too low (≤7.5 mg/day), as these provide inadequate disease control and may lead to prolonged treatment courses 1