What is the first line treatment (tx) for polymyalgia rheumatica (PMR)?

First-Line Treatment for Polymyalgia Rheumatica

Start oral prednisone at 12.5-25 mg daily as first-line therapy for polymyalgia rheumatica, with the specific dose individualized based on body weight, relapse risk factors, and comorbidities. 1, 2

Initial Dosing Strategy

Use 20-25 mg/day prednisone for patients with:

• Female sex 2
• High ESR (>40 mm/hr) 2
• Peripheral arthritis 2
• Higher body weight (>0.19 mg/kg required for response) 3

Use 12.5-15 mg/day prednisone for patients with:

• Diabetes mellitus 1, 2
• Osteoporosis 1, 2
• Glaucoma 1, 2
• Hypertension 1
• Lower body weight 3

Avoid initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect and are associated with higher relapse rates. 1, 4

Strongly avoid initial doses >30 mg/day due to increased adverse effects without additional benefit; patients requiring such doses should be evaluated for alternative diagnoses. 1

Expected Response Timeline

• Clinical improvement should occur within 2-4 weeks of initiating therapy 1, 2
• Most patients respond within 6.6 days on average 3
• If no improvement by 2-4 weeks, reassess the diagnosis and consider increasing the dose or specialist referral 1

Glucocorticoid Tapering Protocol

Initial tapering phase (first 4-8 weeks):

• Reduce prednisone to 10 mg/day within 4-8 weeks once clinical improvement is achieved 1, 2

Maintenance tapering phase:

• Once remission is achieved, decrease by 1 mg every 4 weeks (or use alternating day schemes like 10/7.5 mg on alternate days) until discontinuation 1, 2
• Tapering slower than 1 mg/month (<1 mg/mo) is associated with fewer relapses and more successful treatment cessation 4

Alternative Glucocorticoid Formulation

Intramuscular methylprednisolone (120 mg every 3 weeks) may be considered as an alternative to oral prednisone, particularly for: 1

• Female patients with difficult-to-control hypertension 1
• Patients with diabetes, osteoporosis, or glaucoma where lower cumulative glucocorticoid exposure is desirable 1
• This formulation showed comparable efficacy with less weight gain in trials 1

Glucocorticoid-Sparing Agents

Consider adding methotrexate 7.5-10 mg/week early in treatment for: 1, 2

• High risk of relapse (female sex, ESR >40, peripheral arthritis) 2
• Prolonged therapy requirements 1, 2
• Significant glucocorticoid-related comorbidities 1, 2
• Methotrexate at doses ≥10 mg/week demonstrates glucocorticoid-sparing properties 4

TNF-α blocking agents are ineffective and should not be used for isolated PMR. 1

Management of Relapses

If relapse occurs:

• Increase prednisone to the pre-relapse dose 1, 5
• Taper gradually over 4-8 weeks back to the dose at which relapse occurred 1, 5
• Subsequently reduce by 1 mg per month (slower than initial tapering) 5

Essential Adjunctive Measures

• Initiate bone protection at treatment start (calcium, vitamin D, bisphosphonates as indicated) 2
• Use single daily dosing rather than divided doses, except for prominent night pain when tapering below 5 mg/day 1
• Schedule follow-up visits every 4-8 weeks during the first year 2
• Monitor for adverse effects including blood pressure, glucose, bone density, and ocular complications 2

Common Pitfalls to Avoid

• Starting doses too low (≤7.5 mg/day) leads to inadequate disease control and higher relapse rates 1
• Tapering too rapidly (>1 mg/month) increases relapse risk 4
• Failing to adjust initial dose based on body weight results in suboptimal response in heavier patients 3
• Using NSAIDs instead of glucocorticoids for disease control, as NSAIDs provide only symptomatic relief without modifying disease progression 6