Treatment of Polymyalgia Rheumatica
Start prednisone at 12.5-25 mg daily based on body weight and comorbidity profile, taper to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation. 1
Initial Glucocorticoid Dosing
The cornerstone of PMR treatment is oral glucocorticoids, not NSAIDs. 1 Glucocorticoids are strongly recommended over NSAIDs because they reduce both symptoms and structural progression, whereas NSAIDs provide only symptomatic relief. 1
Dose Selection Algorithm
- For patients weighing <65 kg or with significant comorbidities (diabetes, osteoporosis, glaucoma): Start with 12.5-15 mg/day prednisone 1, 2
- For patients weighing >65 kg with high relapse risk (female sex, ESR >40 mm/hr, peripheral arthritis) and low risk of adverse events: Start with 20-25 mg/day prednisone 1, 2
- Body weight is the primary factor determining response: The effective dose is approximately 0.19 mg/kg 3
The 2015 EULAR/ACR guidelines strongly recommend against initial doses >30 mg/day and conditionally discourage doses ≤7.5 mg/day as insufficient. 1
Expected Response Timeline
Clinical improvement should occur within 7 days of starting therapy. 4 If no significant response occurs within 2-4 weeks at 20 mg/day, consider alternative diagnoses or atypical PMR requiring specialist referral. 1, 4
Tapering Schedule
Initial Tapering Phase (Weeks 0-8)
- Reduce prednisone from starting dose to 10 mg/day over 4-8 weeks 1, 2
- Monitor clinical symptoms and inflammatory markers (ESR, CRP) every 4-8 weeks 1, 2
Maintenance Tapering Phase (After Week 8)
- Once at 10 mg/day and remission is maintained, decrease by 1 mg every 4 weeks 1, 2
- Alternative approach: Use alternating schedules like 10/7.5 mg on alternate days 1
- Continue tapering until complete discontinuation if remission persists 1
A common pitfall is tapering too rapidly below 5 mg/day, which frequently triggers relapses. 4 The majority of relapses occur when prednisone is ≤5 mg/day. 4
Management of Relapses
When relapse occurs during tapering:
- Increase prednisone back to the pre-relapse dose that controlled symptoms 5, 2
- Maintain this dose until remission is re-established 5
- Taper more slowly over 4-8 weeks back to the dose at which relapse occurred 5, 2
- Then reduce by 1 mg per month (slower than initial taper) 5, 2
Glucocorticoid-Sparing Therapy
Add methotrexate 7.5-10 mg weekly for patients with:
- Frequent or multiple relapses 2, 6
- Prolonged therapy requirements 2
- Significant glucocorticoid-related adverse effects or high risk factors (diabetes, osteoporosis) 2, 6
The evidence supporting methotrexate is strong: it allows 88% of patients to discontinue prednisone versus 53% with prednisone alone, reduces flare-ups, and decreases cumulative prednisone dose by approximately 30%. 6 Methotrexate also prevents bone mineral density loss that occurs with prednisone alone. 7
Monitoring Protocol
First Year
- Schedule visits every 4-8 weeks 1, 2
- At each visit assess: clinical symptoms, ESR/CRP, glucocorticoid-related adverse effects, and relapse risk factors 1, 2
Second Year
Ongoing
- Provide rapid access to healthcare for reporting flares or adverse events 1
Essential Adjunctive Measures
Initiate bone protection at treatment start with calcium, vitamin D, and consider bisphosphonates, as prednisone causes significant bone loss in this elderly population. 2, 7 All patients should receive education on disease impact, treatment expectations, and individually tailored exercise programs. 1, 2
Specialist Referral Indications
Refer to rheumatology for: