What are the treatment options for Polymyalgia Rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica (PMR) is best treated with low-dose oral corticosteroids, typically starting with prednisone 12.5-25 mg daily, as recommended by the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) collaborative initiative 1.

Key Considerations

• The initial dose of prednisone should be individualized, taking into account the patient's risk of relapse and side effects, with a higher dose considered for those at high risk of relapse and a lower dose for those with comorbidities or risk factors for glucocorticoid (GC)-related side effects.
• The dose should be gradually tapered by 1 mg every 4 weeks (or similar) once remission is achieved, with the goal of discontinuing treatment while maintaining remission.
• Methotrexate (7.5-10 mg/week) may be considered as a steroid-sparing agent, particularly in patients at high risk of relapse or with a history of GC-related side effects.
• Regular monitoring of symptoms, inflammatory markers (ESR/CRP), and potential steroid side effects is essential to ensure effective treatment and minimize adverse effects.
• Patients should be advised to report any new headaches, vision changes, or jaw pain immediately, as these could indicate giant cell arteritis, a related condition requiring urgent treatment.

Treatment Approach

• Initial treatment: prednisone 12.5-25 mg daily, with individualized dosing based on patient risk factors.
• Tapering schedule: gradual reduction by 1 mg every 4 weeks (or similar) once remission is achieved.
• Steroid-sparing agents: methotrexate (7.5-10 mg/week) may be considered in select patients.
• Monitoring: regular assessment of symptoms, inflammatory markers, and potential steroid side effects.

Supporting Evidence

• The 2015 EULAR/ACR recommendations provide a comprehensive framework for the management of PMR, emphasizing the importance of individualized treatment and regular monitoring 1.
• Studies have demonstrated the efficacy of low-dose oral corticosteroids in treating PMR, with a gradual tapering schedule to minimize side effects and maintain remission.
• Methotrexate has been shown to be effective as a steroid-sparing agent in select patients, particularly those at high risk of relapse or with a history of GC-related side effects.

From the Research

Treatment Options for PMR

• The primary treatment for Polymyalgia Rheumatica (PMR) is glucocorticoids, with prednisone or prednisolone at a dose ranging between 12.5 and 25 mg/day being the agreed-upon treatment 2, 3, 4, 5.
• Glucocorticoid-sparing agents, such as methotrexate, have emerged as tools in the management of PMR to reduce the side effects associated with prolonged glucocorticoid use and the high frequency of relapses when glucocorticoids are tapered 2, 3, 4, 6.
• Biologic agents, particularly anti-IL-6 receptor agents such as tocilizumab and sarilumab, have demonstrated efficacy in reducing relapse frequency, lowering the cumulative glucocorticoid burden, and achieving long-term remission of the disease 2, 3.

Glucocorticoid Treatment

• An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR, generally achieved within 7 days of the onset of this therapy 4.
• Starting prednisone doses higher than 10 mg/d were associated with fewer relapses and shorter therapy than were lower doses 6.
• Slow prednisone dose tapering (<1 mg/mo) was associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 6.

Alternative Therapies

• Methotrexate is the most commonly used corticosteroid sparing agent, and its initial addition has provided efficacy at doses of 10 mg/wk or higher 6.
• Other biologic agents, such as Janus kinase (JAK) inhibitors, are currently under investigation for the treatment of PMR 2, 3.
• Anti-TNF agents have failed to provide beneficial effects in isolated PMR 2, 3.