Treatment of Polymyalgia Rheumatica
Initial Glucocorticoid Therapy
Start prednisone at 12.5-25 mg daily as first-line treatment for PMR, with the specific dose within this range determined by comorbidity burden and relapse risk. 1, 2
- Use 20-25 mg daily for patients with high relapse risk (high ESR >40 mm/hr, peripheral arthritis) and minimal comorbidities 2
- Use 12.5-15 mg daily for patients with significant comorbidities including diabetes, osteoporosis, glaucoma, hypertension, or cardiovascular disease 1, 2
- Doses below 7.5 mg/day are inadequate and should not be used 2
- Doses above 30 mg/day are strongly contraindicated due to excessive adverse effects without additional benefit 2
- Expect dramatic clinical improvement within 7 days; lack of response should prompt reconsideration of the diagnosis 3, 4
Alternative Route
- Intramuscular methylprednisolone 120 mg every 3 weeks can be used as an alternative to oral therapy, particularly for patients with adherence concerns or gastrointestinal intolerance 2
Glucocorticoid Tapering Protocol
Reduce prednisone to 10 mg/day within 4-8 weeks if symptoms are controlled, then taper by 1 mg every 4 weeks (or use alternating-day schedules like 10/7.5 mg) until discontinuation. 2
- The slow tapering rate of <1 mg per month after reaching 10 mg/day is critical—faster tapering increases relapse rates 5
- Most patients require 1-2 years of treatment, though some need up to 4 years 6
- Target maintenance dose of 7.5 mg after 6-9 months if disease remains controlled 6
Common Pitfall
- Tapering too rapidly below 5 mg/day frequently triggers relapses 3, 4. If persistent nighttime pain occurs when tapering below 5 mg/day, split the daily dose (morning and evening) rather than increasing the total dose 2, 7
Management of Relapses
For relapse, increase prednisone back to the pre-relapse dose that controlled symptoms, then reduce over 4-8 weeks to the dose at which relapse occurred. 2, 7
- After re-establishing control, taper more slowly than the initial schedule—no faster than 1 mg per month 2, 7
- Relapses are most common when prednisone is ≤5 mg/day 3, 4
- Do not rely solely on ESR or CRP to guide treatment decisions during relapse—clinical symptoms are paramount 4
Steroid-Sparing Therapy with Methotrexate
Add methotrexate 7.5-10 mg weekly for patients with frequent relapses, prolonged therapy requirements, or significant glucocorticoid-related adverse effects. 2
- Methotrexate is the only steroid-sparing agent with demonstrated efficacy in PMR 5, 3
- Consider methotrexate early for patients with risk factors for glucocorticoid toxicity (diabetes, osteoporosis, prior fractures) 1, 2
- Doses of 10 mg/week or higher are required for efficacy 5
Agents to Avoid
- TNF-α blockers (infliximab, etanercept) are strongly contraindicated—they are ineffective in PMR 2
- Chinese herbal preparations (Yanghe and Biqi capsules) should not be used 2
- NSAIDs provide only symptomatic relief without disease modification and should be reserved for short-term pain control from other conditions, not as primary PMR therapy 1, 2
Baseline Assessment and Monitoring
Before initiating glucocorticoids, obtain: 1
- ESR and/or CRP
- Complete blood count
- Glucose, creatinine, liver function tests
- Calcium, alkaline phosphatase
- Rheumatoid factor and/or anti-CCP antibodies
- Urinalysis
- Consider: protein electrophoresis, TSH, creatine kinase, vitamin D
Follow-up Schedule
- Every 4-8 weeks during the first year 1, 2
- Every 8-12 weeks during the second year 1
- At each visit, assess for glucocorticoid adverse effects (bone density, blood pressure, glucose, cataracts, infections) and document disease activity 1, 2
Specialist Referral Indications
Refer to rheumatology for: 1
- Atypical presentation (age <60 years, low inflammatory markers, peripheral inflammatory arthritis, systemic symptoms)
- Refractory disease despite appropriate glucocorticoid therapy
- Frequent relapses or prolonged therapy requirements
- Significant glucocorticoid-related adverse effects