What is the recommended treatment for polymyalgia rheumatica (PMR)?

Understanding Polymyalgia Rheumatica (PMR): Patient Education

What is PMR?

Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in your shoulders and hips, typically affecting people over 60 years old. 1

• You'll experience bilateral (both sides) shoulder and hip girdle pain with morning stiffness lasting more than 45 minutes 1
• Blood tests will show elevated inflammatory markers (ESR >40 mm/hr or elevated CRP) 1
• This is a treatable condition that responds very well to steroid medication 1

Your Treatment Plan

Starting Medication

Your doctor will prescribe prednisone (a steroid) at a dose between 12.5-25 mg daily as your main treatment. 1

• If you're at higher risk for disease flare-ups (female, very high ESR, joint swelling), you may start closer to 20-25 mg daily 1
• If you have diabetes, osteoporosis, or glaucoma, you'll likely start at the lower end (12.5-15 mg daily) to minimize side effects 1
• You should notice dramatic improvement within days to weeks 2

How Your Dose Will Be Reduced

Your prednisone will be gradually tapered down over many months to prevent disease flare-ups. 1

• Within 4-8 weeks, your dose will be reduced to 10 mg daily 1
• After that, your dose will decrease by 1 mg every 4 weeks until you can stop the medication 1
• The entire treatment course typically lasts 1-2 years or longer 2
• Some patients may need to alternate doses (like 10 mg one day, 7.5 mg the next) during tapering 3

What If Your Symptoms Return (Relapse)?

If your pain and stiffness come back during tapering, your prednisone dose will be increased back to the level that controlled your symptoms. 4

• Your doctor will then taper more slowly than before, reducing by only 1 mg per month 4
• This gradual approach over 4-8 weeks helps prevent another flare-up 4
• If you have persistent nighttime pain when taking less than 5 mg daily, your doctor may split your dose throughout the day 4

Additional Medication You May Need

Methotrexate (Steroid-Sparing Agent)

If you experience frequent relapses or need prolonged steroid treatment, your doctor may add methotrexate (7.5-10 mg weekly) to help reduce your prednisone dose. 1

• Methotrexate is particularly helpful if you're having multiple flare-ups or developing side effects from prednisone 1
• You'll also take folinic acid (7.5 mg weekly) with methotrexate to reduce side effects 5
• Studies show that adding methotrexate allows 88% of patients to stop prednisone compared to only 53% on prednisone alone 5

Bone Protection

You must start bone protection medication immediately when beginning prednisone, as steroids cause significant bone loss. 1, 3

• Take calcium and vitamin D supplements daily 3
• Your doctor will check your bone density and may prescribe a bisphosphonate medication to prevent fractures 3
• This is especially important if you've had previous fractures or anticipate long-term treatment 3

Monitoring and Follow-Up Visits

You'll need frequent follow-up appointments to monitor your disease and medication side effects. 1

• Every 4-8 weeks during your first year of treatment 1
• Every 8-12 weeks during your second year 1
• At each visit, your doctor will assess your symptoms, check inflammatory markers (ESR/CRP), and screen for steroid side effects 1

What Your Doctor Will Monitor

• Blood pressure and blood sugar (prednisone can worsen diabetes and hypertension) 3
• Bone density 3
• Eye health (cataracts and glaucoma risk) 3
• Signs of infection (steroids suppress your immune system) 3
• Weight gain and mood changes 3

Important Things to Know

Common Pitfalls to Avoid

• Never stop prednisone suddenly – this must be done gradually under medical supervision 1
• Don't skip doses – consistent daily dosing is essential for controlling inflammation 1
• Report new symptoms immediately – particularly new headaches, vision changes, or jaw pain, which could indicate giant cell arteritis (a related serious condition) 2

Lifestyle Recommendations

Engage in individually tailored exercise programs to maintain muscle strength and joint flexibility. 1

• Regular physical activity helps counteract steroid-related muscle weakness 1
• Exercise also helps prevent weight gain and maintains bone health 1

When to Seek Specialist Care

You should be referred to a rheumatologist if: 3

• You're younger than 60 years old (atypical for PMR) 3
• Your inflammatory markers are normal despite typical symptoms 3
• You develop peripheral joint swelling or systemic symptoms 3
• Your disease doesn't respond adequately to appropriate prednisone doses 3
• You experience significant steroid-related side effects 3

What to Expect Long-Term

Most patients can eventually stop prednisone completely, though this may take 1-2 years or longer. 2

• About 70% of patients successfully discontinue prednisone without relapse when following the proper tapering schedule 5
• Some patients require longer treatment courses, particularly those with frequent relapses 1
• The total cumulative dose of prednisone is typically lower when methotrexate is added (2.1 g vs 2.97 g) 5

Medications That Don't Work

Avoid TNF-blocking agents (like infliximab) and Chinese herbal preparations (Yanghe and Biqi capsules), as these are not effective for PMR. 3