Initial Treatment for Polymyalgia Rheumatica
Start prednisone 12.5-25 mg daily as first-line therapy for polymyalgia rheumatica. 1
Determining the Initial Dose
The European League Against Rheumatism provides clear guidance on selecting within the 12.5-25 mg range 1:
- Use 20-25 mg daily for patients at high risk of relapse who have low risk of adverse events (younger patients without significant comorbidities) 1
- Use 12.5-15 mg daily for patients with relevant comorbidities including diabetes, osteoporosis, or glaucoma 1
- Avoid doses ≤7.5 mg/day as they are inadequate for initial control 1
- Never exceed 30 mg/day as higher doses provide no additional benefit and increase adverse effects 1
Alternative to Oral Therapy
Intramuscular methylprednisolone 120 mg every 3 weeks can be considered as an alternative to oral glucocorticoids, particularly for patients with adherence concerns or gastrointestinal intolerance 1.
Expected Response and Red Flags
Patients should demonstrate dramatic improvement within 3-7 days of starting therapy 1. If response is inadequate or only partial after 4 weeks, this suggests either incorrect diagnosis or the need for rheumatology referral 1. Specifically refer to rheumatology for:
- Age <60 years 1
- Low inflammatory markers despite typical symptoms 1
- Peripheral inflammatory arthritis 1
- Systemic symptoms beyond typical PMR 1
- Partial response to appropriate glucocorticoid therapy 1
Essential Baseline Testing
Before initiating glucocorticoids, obtain 1:
- ESR and/or CRP
- Glucose
- Creatinine and liver function tests
- Calcium and alkaline phosphatase
- Urinalysis
- Consider: protein electrophoresis, TSH, creatine kinase, vitamin D
Mandatory Bone Protection
All patients require calcium and vitamin D supplementation from day one 1. Assess bone mineral density and strongly consider bisphosphonate therapy, particularly for patients with prior fractures or anticipated prolonged treatment 1.
Initial Tapering Strategy
Reduce to 10 mg/day within 4-8 weeks once remission is achieved 1. This relatively rapid initial taper is safe and appropriate when symptoms are well-controlled 1. After reaching 10 mg/day, taper by 1 mg every 4 weeks until discontinuation 1, 2.
When to Add Methotrexate
Consider adding methotrexate 7.5-10 mg weekly as adjunctive therapy from the outset for 1:
- Patients at high risk for relapse
- Patients with risk factors for glucocorticoid-related adverse events
- Patients anticipated to require prolonged therapy
Research supports this approach, with one trial demonstrating that 88% of patients on prednisone plus methotrexate successfully discontinued prednisone by 76 weeks compared to only 53% on prednisone alone 3.
Follow-Up Schedule
Schedule visits every 4-8 weeks during the first year to monitor disease activity, laboratory markers (ESR, CRP), and adverse events 1. This frequent monitoring allows for individualized dose adjustments and early detection of complications 1.
Common Pitfalls to Avoid
- Starting with doses <12.5 mg/day, which leads to inadequate symptom control 1
- Using doses >30 mg/day, which increases adverse effects without improving efficacy 1
- Failing to initiate bone protection immediately 1
- Tapering too quickly before 4-8 weeks, which increases relapse risk 1
- Missing atypical features that warrant rheumatology referral 1