What is the best management plan for a 66-year-old patient with recurrent polymyalgia rheumatica, recent fall injuries, and a history of migraines, who is currently on prednisolone, Celebrex (celecoxib), and paracetamol (acetaminophen), and has a resolved breast lesion?

Management of Recurrent Polymyalgia Rheumatica with Fall Injuries

Continue prednisolone 20 mg daily for the planned 6-week course, then implement a gradual taper by reducing to the pre-relapse dose over 4-8 weeks, followed by slower decrements of 1 mg every 4 weeks once remission is achieved. 1, 2

Polymyalgia Rheumatica Management

Current Glucocorticoid Approach

• The current dose of 20 mg prednisolone daily is appropriate for this recurrent episode and falls within the EULAR/ACR recommended initial range of 12.5-25 mg daily 1, 3
• After completing the planned 6-week course at 20 mg, reduce to 10 mg daily over 4-8 weeks 1, 3
• Once remission is achieved, taper by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg) until discontinuation 1, 2, 3
• For this patient with a second recurrence this year, the tapering must be slower than the initial attempt - do not exceed 1 mg reduction per month 2

Critical Consideration for Steroid-Sparing Therapy

• Given this is the second PMR episode this year (recurrent relapses), strongly consider adding methotrexate 7.5-10 mg weekly as a glucocorticoid-sparing agent 1, 3
• Methotrexate is particularly indicated in patients at high risk for relapse (which this patient clearly demonstrates) and those requiring prolonged therapy 1, 3
• This decision should be made in consultation with rheumatology, which is appropriately planned within 6 weeks 3

Monitoring Relapse Risk

• Relapses most commonly occur when prednisolone is reduced below 5-7.5 mg daily 2, 4
• The speed of glucocorticoid tapering is the main modifiable factor influencing relapse development 4
• If prominent nighttime pain develops when tapering below 5 mg daily, consider splitting the daily dose rather than maintaining a single morning dose 1, 3

Fall Injury Management

Immediate Assessment Priorities

• Schedule a separate consultation urgently for formal musculoskeletal examination of the left hip, shoulder, and ribs [@case details]
• Obtain plain radiographs of the left hip, shoulder, and ribs if pain persists beyond 1-2 weeks or if there are concerning examination findings (limited range of motion, severe tenderness, inability to bear weight) [@clinical practice]
• The combination of glucocorticoids and fall risk is particularly concerning - this patient is at increased risk for fractures and requires bone health optimization 3

Fall Prevention Strategy

• Implement an individualized exercise program immediately aimed at maintaining muscle mass and function, and reducing fall risk - this is specifically recommended for older PMR patients on long-term glucocorticoids 1
• Assess home safety and consider physical therapy referral for gait training and balance exercises [@clinical practice]

Celecoxib (Celebrex) Safety Concerns

Critical Drug Interaction Risk

• The concurrent use of celecoxib with prednisolone significantly increases gastrointestinal bleeding risk [@7@]
• Concomitant use of oral corticosteroids and NSAIDs increases the risk of serious GI events including bleeding, ulceration, and perforation [@7@]
• Consider discontinuing celecoxib and using paracetamol alone for pain management, as the GI risk outweighs benefits in this context 5

Cardiovascular Considerations

• At age 66 with hypertension (BP 160/72), this patient has cardiovascular risk factors [@case details]
• Celecoxib carries cardiovascular thrombotic event risks (MI, stroke), particularly with prolonged use 5
• If celecoxib must be continued, use the lowest effective dose for the shortest duration possible 5

Bone Health Protection

Essential Osteoporosis Prophylaxis

• All patients on chronic glucocorticoids require calcium 800-1,000 mg daily and vitamin D 400-800 units daily 3
• Obtain baseline bone mineral density (DEXA scan) if not already done 3
• Consider bisphosphonate therapy given the recurrent PMR requiring prolonged glucocorticoid treatment and recent fall 3
• This is particularly critical as glucocorticoids cause significant bone loss and this patient has already experienced a fall 3

Hypertension Management

Blood Pressure Optimization

• The current BP of 160/72 mmHg requires attention - glucocorticoids can worsen hypertension [@case details]
• Monitor BP closely during glucocorticoid therapy and adjust antihypertensive medications as needed [@clinical practice]
• NSAIDs like celecoxib can also elevate blood pressure (4.2% incidence in clinical trials), providing another reason to discontinue it 5

Breast Lesion Follow-Up

Imaging Surveillance

• Proceed with the requested breast imaging despite symptom resolution - a palpable breast lump requires definitive evaluation regardless of current symptoms [@case details]
• The 3-4 month wait time is acceptable for a resolved lesion, but instruct the patient to return immediately if symptoms recur, the lump enlarges, or new concerning features develop (skin changes, nipple discharge, axillary masses) [@clinical practice]

Rheumatology Referral Urgency

Specialist Consultation Timing

• The 6-week rheumatology appointment is appropriate and should be maintained 3
• Referral is indicated for recurrent/relapsing disease, which this patient clearly demonstrates 3
• The rheumatologist will guide decisions regarding methotrexate initiation and long-term glucocorticoid tapering strategy 3
• If the patient is not seen by rheumatology before prednisolone needs to be tapered below 10 mg daily, contact rheumatology for guidance rather than proceeding independently [@case details]

Common Pitfalls to Avoid

• Do not taper glucocorticoids too rapidly - this is the primary cause of relapses in PMR [@14@]
• Do not rely solely on ESR/CRP to guide tapering - these markers did not predict relapse in clinical studies and are currently normal in this patient despite active disease [@12@]
• Do not continue dual therapy with celecoxib and prednisolone long-term due to compounded GI bleeding risk 5
• Do not neglect bone health prophylaxis - this is non-negotiable in patients requiring prolonged glucocorticoid therapy [@