What is the recommended management for Polymyalgia Rheumatica (PMR)?

Management of Polymyalgia Rheumatica

Start prednisone at 12.5-25 mg daily as first-line therapy, with the specific dose determined by relapse risk factors and comorbidity burden. 1, 2

Initial Dose Selection

The choice between 12.5 mg and 25 mg prednisone daily depends on two competing considerations:

Use higher doses (20-25 mg/day) for patients with: 2

• Female sex
• ESR >40 mm/hr
• Peripheral inflammatory arthritis
• Age ≥60 years with typical presentation
• Absence of significant comorbidities

Use lower doses (12.5-15 mg/day) for patients with: 1, 2

• Diabetes mellitus
• Osteoporosis
• Glaucoma
• Hypertension
• Cardiovascular disease
• Peptic ulcer disease

The European League Against Rheumatism guidelines provide this dose range specifically to allow individualization based on these factors, rather than using a one-size-fits-all approach. 1

Expected Response and Red Flags

Clinical improvement should occur within 7 days of starting therapy. 3 If a patient does not respond adequately to 20 mg/day prednisone within one week, reconsider the diagnosis—this may not be isolated PMR. 3

Tapering Protocol

Initial Taper (First 4-8 Weeks)

Reduce prednisone to 10 mg/day within 4-8 weeks of starting therapy. 1, 2 This relatively rapid initial taper is safe once symptoms are controlled and helps minimize cumulative steroid exposure. 4

Maintenance Taper (After Reaching 10 mg/day)

Decrease by 1 mg every 4 weeks until discontinuation. 1, 5, 2 This slow taper rate (1 mg per month) is critical for minimizing relapse risk, which increases substantially with faster tapering. 4

Alternative dosing schedules (such as alternating 10 mg and 7.5 mg every other day) can be used during this phase. 5, 2

Management of Relapses

Relapses are common, particularly when prednisone is reduced to ≤5 mg/day. 5, 3

For relapse on ≤5 mg/day: 5

• Return to the previous dose that controlled symptoms
• Re-establish remission over 4-8 weeks
• Resume tapering at 1 mg per month (slower than the initial taper)

For persistent nighttime pain when reducing below 5 mg/day: 5

• Consider splitting the daily dose rather than increasing total dose

Glucocorticoid-Sparing Agents

Methotrexate

Add methotrexate 7.5-10 mg weekly for: 2

• Multiple or frequent relapses
• Prolonged therapy requirements (>2 years anticipated)
• Significant glucocorticoid-related adverse effects
• High-risk comorbidities requiring lower steroid exposure

Methotrexate is the most commonly used steroid-sparing agent and has the strongest evidence base among conventional DMARDs. 6, 3

Biologic Agents

Consider tocilizumab or sarilumab for: 6

• Refractory disease despite methotrexate
• Intolerable glucocorticoid toxicity
• Frequent relapses requiring repeated dose escalations

Anti-IL-6 receptor agents (tocilizumab and sarilumab) have demonstrated efficacy in reducing relapse frequency and cumulative glucocorticoid burden. 6 Anti-TNF agents have failed to show benefit in isolated PMR. 6

Monitoring Schedule

Follow-up visits: 1, 2

• Every 4-8 weeks during the first year
• Every 8-12 weeks in the second year
• As needed for relapses or dose adjustments

At each visit, assess: 1, 2

• Clinical symptoms (pain, stiffness)
• Inflammatory markers (ESR, CRP)
• Glucocorticoid-related adverse effects
• Comorbidity status

Essential Adjunctive Measures

Initiate bone protection at treatment start. 2 Prednisone causes significant bone loss, and osteoporosis prophylaxis is mandatory, not optional.

Provide patient education on: 1, 2

• Expected disease course and treatment duration (typically 1-4 years)
• Symptoms of relapse
• Steroid side effects to monitor
• Importance of adherence to tapering schedule

Recommend individually tailored exercise programs to maintain function and prevent deconditioning. 1, 2

Specialist Referral Indications

Refer to rheumatology for: 1

• Age <60 years
• Atypical presentations (peripheral inflammatory arthritis, systemic symptoms)
• Low or normal inflammatory markers despite typical symptoms
• Inadequate response to 20 mg prednisone within 7 days
• Refractory disease or frequent relapses
• High risk of therapy-related complications

Common Pitfalls

The most frequent error is tapering too quickly after the initial response, which substantially increases relapse risk. 4 The second common mistake is failing to initiate bone protection at treatment onset. 2 Finally, continuing to escalate steroids without considering alternative diagnoses when response is inadequate represents a critical missed opportunity for correct diagnosis. 3