From the Guidelines
For polymyalgia rheumatica (PMR), a steroid taper should be individualized, but typically starts with a dose of 12.5-25 mg prednisone equivalent daily, tapering to 10 mg/day within 4-8 weeks, and then further reducing by 1 mg every 4 weeks until discontinuation, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The initial dose and tapering schedule may vary depending on the patient's disease activity, laboratory markers, and adverse events.
- Key principles of glucocorticoid (GC) dose tapering include:
- Initial tapering: Taper dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks.
- Relapse therapy: Increase oral prednisone to the pre-relapse dose and decrease it gradually (within 4–8 weeks) to the dose at which the relapse occurred.
- Tapering once remission is achieved: Taper daily oral prednisone by 1 mg every 4 weeks (or by 1.25 mg decrements using schedules such as 10/7.5 mg alternate days, etc) until discontinuation given that remission is maintained, as suggested by the 2015 recommendations 1. Regular monitoring of patient disease activity, laboratory markers, and adverse events is crucial to guide the tapering process.
- The use of methotrexate or other steroid-sparing agents may be considered to reduce the overall steroid exposure, particularly in patients at high risk for relapse and/or prolonged therapy, as conditionally recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The entire taper process usually takes 1-2 years, though some patients require longer treatment.
- It is essential to monitor patients for symptom recurrence, which may require temporarily increasing the dose before resuming the taper, and to provide calcium and vitamin D supplements to prevent steroid-induced osteoporosis.
From the Research
Steroid Taper for PMR
- The optimal duration for steroid taper in Polymyalgia Rheumatica (PMR) is not strictly defined, but studies suggest that a slow tapering regimen is associated with fewer relapses and more frequent glucocorticoid treatment cessation 2.
- A study published in 2004 found that prednisone dosage (25 mg/d) was tapered to 0 mg/d within 24 weeks, with adjustments made if flare-ups occurred 3.
- Another study from 2009 recommended that reductions in prednisone dose below 10 mg/d should preferably follow a tapering rate of less than 1 mg/mo 2.
- The initial dose of prednisone for PMR treatment is typically in the range of 10-20 mg/day, with clinical improvement usually achieved within 7 days of onset of therapy 4, 5.
- Relapses of PMR are not uncommon when the dose of prednisone is equal to or below 5 mg/day, highlighting the need for careful tapering and monitoring 4.
Factors Influencing Steroid Taper
- The use of methotrexate as a corticosteroid-sparing agent may allow for shorter prednisone treatment and steroid sparing in patients with PMR 3, 6.
- The starting dose of prednisone and the rate of tapering can impact the duration of steroid treatment and the risk of relapse 2.
- Patient factors, such as age and comorbidities, may also influence the optimal steroid taper regimen for PMR treatment 4, 5.