From the Guidelines
The first-line treatment for polymyalgia rheumatica (PMR) is low-dose oral glucocorticoids, specifically prednisone, with a recommended initial dose of 12.5-25 mg daily. This recommendation is based on the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative, which strongly recommends using glucocorticoids (GC) instead of NSAIDs in patients with PMR 1. The panel conditionally recommends using the minimum effective GC dose within the specified range as the initial treatment of PMR, considering individual patient factors such as risk of relapse and comorbidities.
Key principles of glucocorticoid treatment in PMR include:
- Using the minimum effective individualised duration of GC therapy
- Individualising dose tapering schedules based on regular monitoring of patient disease activity, laboratory markers, and adverse events
- Tapering the dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks
- Gradually decreasing the dose by 1 mg every 4 weeks until discontinuation, provided remission is maintained
It is essential to initiate treatment promptly once the diagnosis is confirmed, with most patients experiencing significant symptom improvement within 24-48 hours. Regular monitoring for symptom control, medication side effects, and potential development of giant cell arteritis is crucial throughout treatment 1.
From the FDA Drug Label
Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: ...
The FDA drug label does not answer the question.
From the Research
First Line Treatment for Polymyalgia Rheumatica
- The first line treatment for polymyalgia rheumatica (PMR) is based on low-dose glucocorticoids, with prednisone being the most commonly used medication 2, 3, 4, 5.
- The optimal starting dose of prednisone is between 10-20 mg/day, with most patients experiencing clinical improvement within 7 days of treatment 2, 3, 4, 5.
- A starting dose of 15 mg/day is often recommended, with reductions below 10 mg/day preferably following a tapering rate of less than 1 mg/month 2, 3.
- Methotrexate is commonly used as a glucocorticoid-sparing agent, particularly in patients with relapses or those at high risk for steroid-related toxicity 2, 4, 5, 6.
- The use of other disease-modifying antirheumatic drugs (DMARDs) and biologic agents, such as anti-tumor necrosis factor agents, is not supported by current evidence, although some studies suggest potential benefits with the use of tocilizumab and Janus-kinase inhibitors 4.
Treatment Outcomes and Relapses
- Patients with PMR can experience relapses, particularly when the dose of prednisone is reduced to 5 mg/day or lower 5.
- The addition of methotrexate to prednisone treatment can reduce the risk of relapse and allow for shorter treatment duration with prednisone 6.
- Osteoporosis prophylaxis is recommended for patients with PMR, particularly those receiving long-term glucocorticoid treatment 5.
Treatment Strategies
- Treatment strategies for PMR should be individualized, taking into account the patient's clinical presentation, disease severity, and risk factors for steroid-related toxicity 2, 3, 4, 5.
- Regular monitoring of disease activity and adjustment of treatment as needed can help minimize relapses and optimize treatment outcomes 2, 3, 4, 5.