What is the typical treatment for Polymyalgia Rheumatica (PMR)?

Treatment of Polymyalgia Rheumatica

Start oral prednisone at 12.5-25 mg daily, with the specific dose determined by balancing relapse risk against comorbidities, then taper to 10 mg/day within 4-8 weeks and continue gradual reduction by 1 mg every 4 weeks once remission is achieved. 1

Initial Glucocorticoid Therapy

Oral prednisone is the cornerstone of PMR treatment. 2, 1 The recommended starting dose range is 12.5-25 mg daily, with dose selection based on individual patient factors 2, 1:

• Use higher doses (closer to 25 mg) for patients at high risk of relapse or prolonged therapy, particularly those with high ESR (>40 mm/hour), peripheral inflammatory arthritis, or female sex 2, 1
• Use lower doses (closer to 12.5 mg) for patients with comorbidities that increase glucocorticoid-related adverse event risk, including diabetes, osteoporosis, glaucoma, hypertension, cardiovascular disease, or peptic ulcer 2, 1
• Never use initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect 1
• Never exceed 30 mg/day as initial therapy due to excessive adverse effect risk 1

Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral therapy, though it is not available in all countries and long-term benefits remain uncertain 2, 1. A single trial showed fewer side effects (particularly weight gain) compared to oral therapy, but the study was not powered to demonstrate non-inferiority and could not exclude efficacy differences 2.

Glucocorticoid Tapering Protocol

The tapering schedule should be structured in two phases: 1

Phase 1: Initial Rapid Taper (Weeks 0-8)

• Reduce to 10 mg/day within 4-8 weeks after starting therapy 1
• Clinical improvement should be evident within 2-4 weeks; if not, reconsider the diagnosis 2

Phase 2: Slow Maintenance Taper

• Once remission is achieved, reduce by 1 mg every 4 weeks (or use alternating-day schedules like 10/7.5 mg) 1
• Tapering rates slower than 1 mg/month are associated with fewer relapses and more successful treatment cessation 3
• Target complete discontinuation, though some patients require 2-4 years of therapy 4
• Maintenance dose of 7.5 mg after 6-9 months is typically sufficient for most patients 4

Management of Relapses

Relapses are common, particularly when prednisone is reduced to ≤5 mg/day. 5, 6 When relapse occurs:

• Increase prednisone to the pre-relapse dose that previously controlled symptoms 1, 6
• Gradually decrease over 4-8 weeks back to the dose at which relapse occurred 1, 6
• After re-establishing control, taper more slowly than initially, not exceeding 1 mg per month 1, 6
• For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1, 6

Steroid-Sparing Agents

Methotrexate (7.5-10 mg weekly) should be added in specific clinical scenarios 1:

• Patients at high risk for relapse or requiring prolonged therapy 1
• Patients with risk factors for glucocorticoid-related adverse events 1
• Patients who have experienced relapses despite appropriate glucocorticoid therapy 1
• Patients experiencing significant glucocorticoid-related adverse effects 1

Methotrexate demonstrates glucocorticoid-sparing properties at doses of 10 mg/week or higher 3, though the evidence base is limited. Azathioprine may also be used as a steroid-sparing agent 4.

Medications to Avoid

TNF-α blocking agents (such as infliximab) are strongly contraindicated for PMR treatment, as they have been shown to be ineffective 1, 3. Chinese herbal preparations (Yanghe and Biqi capsules) are also strongly recommended against 1.

Pre-Treatment Assessment and Monitoring

Before initiating glucocorticoids, obtain: 1

• ESR and/or CRP
• Glucose, creatinine, liver function tests
• Calcium, alkaline phosphatase, urinalysis
• Consider: protein electrophoresis, TSH, creatine kinase, vitamin D

Document a minimal clinical and laboratory dataset including assessment of comorbidities, other medications, and risk factors for steroid-related side effects and relapse 2.

Follow-up schedule: 1

• Every 4-8 weeks during the first year
• Every 8-12 weeks during the second year
• At each visit, assess disease activity, inflammatory markers (ESR, CRP), and glucocorticoid-related adverse effects 1, 6

Osteoporosis Prophylaxis

All patients on chronic glucocorticoids require: 1

• Calcium and vitamin D supplementation
• Bone mineral density assessment
• Consider bisphosphonate therapy, particularly for patients with prior fractures or anticipated prolonged treatment 1

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
• Significant glucocorticoid-related adverse effects
• High risk of side effects, relapse, or prolonged therapy 2

Common Pitfalls

Weight-based dosing matters: Research demonstrates that the prednisone dose per kilogram body weight predicts response, with responders receiving approximately 0.19 mg/kg versus 0.16 mg/kg in non-responders 7. This explains why a fixed 12.5 mg dose is sufficient in only 78% of patients, with lower-weight individuals (particularly women) responding better 7.

PMR is heterogeneous: Approximately 30% of patients have low ESR at presentation and respond rapidly with shorter treatment duration (<1 year), while others require prolonged therapy with elevated IL-6 levels persisting despite ESR normalization 8. This heterogeneity should inform individualized treatment duration expectations.