From the Guidelines
For tapering prednisone from 25 mg in polymyalgia rheumatica (PMR), I recommend a gradual reduction schedule to minimize risk of disease flare and adrenal insufficiency, starting by tapering the dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks, then slowing the taper to 1 mg reductions every 4 weeks until complete discontinuation, as suggested by the 2015 recommendations for the management of PMR 1.
Key Considerations
- The initial tapering should aim to reach 10 mg/day prednisone equivalent within 4–8 weeks, as recommended by the panel 1.
- 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, until discontinuation, given that remission is maintained 1.
- Monitor for symptom recurrence during the taper, particularly morning stiffness, shoulder/hip pain, and elevated inflammatory markers, and adjust the taper schedule as needed 1.
- Consider calcium and vitamin D supplementation during steroid treatment to prevent bone loss, especially in patients with risk factors for osteoporosis 1.
Tapering Schedule
- Start by decreasing the dose by 2.5-5 mg every 2-4 weeks until reaching 10 mg daily, based on individual patient response and disease activity.
- Then, slow the taper to 1 mg reductions every 4 weeks until complete discontinuation, as recommended by the panel 1.
Special Considerations
- Patients with a high risk of relapse and low risk of adverse events may require a higher initial prednisone dose, whereas those with relevant comorbidities and other risk factors for GC-related side effects may require a lower dose 1.
- Consider early introduction of methotrexate (MTX) in addition to GCs, particularly in patients at high risk for relapse and/or prolonged therapy, as well as in cases with risk factors, comorbidities, and/or concomitant medications where GC-related adverse events are more likely to occur 1.
From the Research
Tapering Steroids in Polymyalgia Rheumatica (PMR)
- The standard treatment for PMR involves the use of steroids, with the goal of inducing remission and preventing relapse 2.
- Studies have shown that a slow tapering regimen from a low initial steroid dose (between 10 and 20 mg) can help minimize the risk of relapse and steroid-induced adverse events 3.
- In one study, patients with PMR were started on a prednisone dosage of 25 mg/d, which was tapered to 0 mg/d within 24 weeks 4.
- The use of steroid-sparing agents, such as methotrexate, has been shown to be effective in reducing the cumulative steroid dose and the number of flare-ups in PMR patients 4, 5, 6.
- Methotrexate has been found to be a useful addition to steroid treatment in PMR, allowing for a reduction in steroid dosage and sparing of bone in elderly patients at increased risk of osteoporotic fractures 5.
Steroid Tapering Regimens
- A study found that patients who received methotrexate plus prednisone had a lower cumulative prednisone dose and fewer flare-ups compared to those who received prednisone alone 4.
- Another study found that methotrexate-treated patients had lower ESR and CRP levels, and a lower incidence of PMR flare-ups, compared to controls 6.
- The optimal steroid tapering regimen for PMR is still unclear, and more research is needed to determine the best approach 3.
- Individualization and close monitoring of patients during the steroid-tapering process are important to minimize the risk of relapse and steroid-induced adverse events 3.
Steroid-Sparing Agents
- Methotrexate is the most commonly used steroid-sparing agent in PMR, and has been shown to be effective in reducing the cumulative steroid dose and the number of flare-ups 4, 5, 6.
- Other steroid-sparing agents, such as tocilizumab and sarilumab, have also been studied in PMR, but more research is needed to fully establish their efficacy 3, 2.
- The use of steroid-sparing agents can help reduce the risk of steroid-induced adverse events and improve outcomes in PMR patients 3, 2.