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

Treatment of Polymyalgia Rheumatica

Start prednisone at 12.5-25 mg daily based on individual risk factors, taper to 10 mg within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation. 1

Initial Prednisone Dosing Strategy

The dose selection depends on balancing relapse risk against glucocorticoid-related adverse effects:

• Use 20-25 mg/day for patients at high risk of relapse: female sex, ESR >40 mm/hr, or peripheral arthritis, particularly when comorbidities are minimal 1
• Use 12.5-15 mg/day for patients with significant comorbidities: diabetes, osteoporosis, or glaucoma where glucocorticoid side effects pose greater concern 1

This individualized approach is supported by the European League Against Rheumatism guidelines and represents a shift from older fixed-dose regimens 1. Historical data showed that starting doses of 10 mg/day resulted in 65% relapse rates, while 15-20 mg/day achieved better control 2. The current evidence favors starting at the lower end of the therapeutic range when possible to minimize cumulative steroid exposure 3, 4.

Glucocorticoid Tapering Protocol

The tapering schedule is critical to preventing relapses while minimizing steroid exposure:

• Weeks 0-8: Reduce from starting dose to 10 mg/day 1
• After week 8: Decrease by 1 mg every 4 weeks during maintenance phase 1
• Alternative approach for doses below 10 mg: Use alternating schemes (e.g., 10/7.5 mg every other day) to achieve gradual reductions 5

Slow tapering rates (<1 mg/month) are associated with fewer relapses and higher rates of successful glucocorticoid discontinuation compared to faster reduction schedules 4. The majority of relapses occur when prednisone doses fall to or below 5 mg/day 6.

Management of Disease Relapses

When relapse occurs, increase prednisone to the pre-relapse dose that controlled symptoms:

• Return to the previous effective dose immediately 5
• Re-establish disease control over 4-8 weeks 5
• Resume tapering at a slower rate (1 mg every 4 weeks) once remission is achieved 1, 5
• For persistent nighttime pain when reducing below 5 mg/day, consider splitting the daily dose 5

Glucocorticoid-Sparing Therapy with Methotrexate

Add methotrexate 7.5-10 mg weekly for patients with:

• Multiple or frequent relapses 1, 5
• Prolonged therapy requirements (>2 years anticipated) 1
• Significant glucocorticoid-related adverse effects 1
• High-risk features for relapse (female sex, ESR >40, peripheral arthritis) 1

Methotrexate at doses of 10 mg/week or higher demonstrates glucocorticoid-sparing efficacy 4. This should be considered early in patients with predictable risk factors rather than waiting for multiple relapses to occur 1.

Monitoring Schedule and Parameters

Follow-up visits should occur:

• Every 4-8 weeks during the first year 1, 5
• Every 8-12 weeks in the second year 1
• As needed for relapses or dose adjustments 1

At each visit, assess:

• Clinical symptoms (bilateral shoulder/hip girdle pain, morning stiffness) 5
• Inflammatory markers (ESR and CRP) 5
• Glucocorticoid-related adverse effects 5
• Risk factors for relapse 5

Note that ESR and CRP do not reliably predict relapse, and some patients maintain elevated interleukin-6 levels despite clinical improvement 2, 7. Clinical symptoms remain the primary guide for treatment adjustments.

Essential Adjunctive Measures

Initiate bone protection at treatment start with calcium, vitamin D, and bisphosphonates as indicated, since prednisone causes significant bone loss even at low doses 1.

Provide patient education on disease expectations, typical treatment duration (often 1-2 years or longer), and the importance of gradual dose reductions 1.

Recommend individually tailored exercise programs to maintain muscle strength and joint mobility 1.

Critical Diagnostic Considerations

PMR should be suspected in patients meeting these criteria:

• Age ≥60 years (younger patients require specialist referral for atypical presentation) 1
• Bilateral shoulder and hip girdle pain with morning stiffness >45 minutes 1
• ESR >40 mm/hr or elevated CRP 1

Common pitfall: If patients do not respond adequately to 20 mg/day prednisone within 7 days, strongly consider alternative diagnoses such as rheumatoid arthritis, malignancy, or infection 6. The dramatic response to glucocorticoids is a hallmark of PMR, and lack of response should prompt diagnostic reconsideration.