What is the recommended treatment for a patient diagnosed with Polymyalgia Rheumatica (PMR)?

Treatment of Polymyalgia Rheumatica

Start prednisone at 12.5-25 mg daily based on body weight and risk factors, with higher doses (20-25 mg) for patients at high relapse risk and lower doses (12.5-15 mg) for those with comorbidities like diabetes or osteoporosis. 1

Initial Dosing Strategy

The European League Against Rheumatism provides clear guidance on individualizing the starting dose based on specific patient characteristics 1:

• Use 20-25 mg/day for patients with high relapse risk factors including female sex, ESR >40 mm/hr, or peripheral arthritis, particularly if they have low risk of glucocorticoid adverse events 1
• Use 12.5-15 mg/day for patients with relevant comorbidities such as diabetes, osteoporosis, or glaucoma 1
• Body weight is the primary determinant of response—the effective dose is approximately 0.19 mg/kg 2

Most patients (78%) respond adequately to 12.5 mg prednisone if their body weight is low, with clinical improvement typically occurring within 6-7 days 2. Starting doses above 15 mg/day are associated with more glucocorticoid-related adverse effects, while doses below 10 mg/day result in more relapses 3.

Tapering Protocol

Taper prednisone to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation, provided remission is maintained. 1

The tapering schedule follows this algorithm 1:

• Weeks 0-8: Reduce from starting dose to 10 mg/day over 4-8 weeks
• After week 8: Decrease by 1 mg every 4 weeks during maintenance phase
• Slow tapering (<1 mg/month) below 10 mg/day is critical—faster tapering results in more relapses and less frequent treatment cessation 3

Management of Relapses

For relapse, increase prednisone to the pre-relapse dose, then taper more slowly (over 4-8 weeks) back to the dose at which relapse occurred, followed by reduction of 1 mg per month. 1, 4

Relapses are common when prednisone is at or below 5 mg/day 5. The management approach is 4:

• Return to the previous dose that controlled symptoms effectively
• Re-establish remission over 4-8 weeks
• Resume tapering at a slower rate (1 mg per month maximum)
• For persistent nighttime pain below 5 mg/day, consider splitting the daily dose 4

Glucocorticoid-Sparing Therapy

Add methotrexate 7.5-10 mg weekly for patients with frequent relapses, prolonged therapy requirements, or significant glucocorticoid-related adverse effects. 1

The evidence supporting methotrexate includes 6:

• 88% of patients on prednisone plus methotrexate discontinued prednisone by 76 weeks versus 53% on prednisone alone (risk difference 34 percentage points)
• Methotrexate reduces flare-ups (47% vs 73% experiencing at least one flare-up)
• Median cumulative prednisone dose is reduced from 2.97 g to 2.1 g
• Methotrexate at 10 mg/week or higher demonstrates glucocorticoid-sparing properties 3

Specific indications for adding methotrexate 1:

• Multiple or frequent relapses
• High-risk factors for relapse (female sex, ESR >40, peripheral arthritis)
• Risk factors for glucocorticoid adverse events (diabetes, osteoporosis, glaucoma)
• Prolonged therapy requirements

Monitoring Schedule

Schedule visits every 4-8 weeks during the first year, every 8-12 weeks in the second year, and as needed for relapses or dose adjustments. 1

At each visit, assess 1, 4:

• Clinical symptoms (bilateral shoulder/hip girdle pain, morning stiffness)
• Inflammatory markers (ESR and CRP)
• Glucocorticoid-related adverse effects
• Risk factors for relapse

Essential Adjunctive Measures

Initiate bone protection at treatment start, as prednisone causes significant bone loss. 1

Additional measures include 1:

• Calcium and vitamin D supplementation
• Consider bisphosphonates for osteoporosis prophylaxis
• Patient education on disease course and treatment expectations
• Individually tailored exercise programs

Common Pitfalls to Avoid

• Starting doses below 10 mg/day provide insufficient anti-inflammatory effect and result in more relapses 3
• Tapering faster than 1 mg/month below 10 mg/day increases relapse risk 3
• Failing to consider body weight when dosing—lighter patients may respond to lower doses 2
• Not recognizing that lack of response to 20 mg/day prednisone within 7 days should prompt consideration of alternative diagnoses 5