From the Guidelines
The first-line treatment for polymyalgia rheumatica is low-dose oral glucocorticoids, specifically prednisone, with an initial dose of 12.5-25 mg daily. This recommendation is based on the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative, which strongly recommends using glucocorticoids (GC) instead of NSAIDs in patients with PMR 1. The panel conditionally recommends using the minimum effective GC dose within the range of 12.5–25 mg prednisone equivalent daily as the initial treatment of PMR.
When initiating treatment, it is essential to consider the individual patient's risk factors for glucocorticoid-related side effects, such as diabetes, osteoporosis, and glaucoma. A higher initial prednisone dose within the recommended range may be considered in patients with a high risk of relapse and low risk of adverse events, whereas a lower dose may be preferred in patients with relevant comorbidities 1.
The treatment regimen typically involves an initial tapering of the dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks, followed by gradual tapering by 1 mg every 4 weeks until discontinuation, provided that remission is maintained 1. It is crucial to monitor patient disease activity, laboratory markers, and adverse events regularly to adjust the dose tapering schedule accordingly.
Key considerations in the management of PMR include:
- Regular monitoring of patient disease activity and laboratory markers
- Individualized dose tapering schedules
- Calcium and vitamin D supplementation for bone protection
- Monitoring for glucocorticoid side effects, including osteoporosis, diabetes, hypertension, and weight gain
- Consideration of methotrexate as a steroid-sparing agent in patients who cannot tolerate glucocorticoids or have an inadequate response 1.
From the Research
First Line Treatment for Polymyalgia Rheumatica
- The first line treatment for polymyalgia rheumatica (PMR) is corticosteroids, specifically prednisone 2, 3, 4, 5.
- An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR, generally achieved within 7 days of the onset of this therapy 4.
- The optimal starting dose and tapering regimen of prednisone are still debated, but starting doses higher than 10 mg/d are associated with fewer relapses and shorter therapy than lower doses 5.
- Slow prednisone dose tapering (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 5.
Role of Methotrexate
- Methotrexate is the most commonly used corticosteroid-sparing agent in PMR 4, 6.
- Methotrexate has been shown to be effective in reducing glucocorticoid dose and improving inflammatory activity in patients with PMR 3, 6.
- However, methotrexate is often associated with a relatively high risk of adverse events, and its use should be carefully considered on a case-by-case basis 6.