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 body weight and comorbidity profile, with higher doses (20-25 mg) for patients at high relapse risk and lower doses (12.5-15 mg) for those with diabetes, osteoporosis, or glaucoma. 1

Initial Treatment Strategy

The cornerstone of PMR management is oral glucocorticoids, with the specific starting dose determined by patient characteristics 1:

• For patients with high relapse risk (female sex, ESR >40, peripheral arthritis) and no significant comorbidities: use 20-25 mg/day 1
• For patients with relevant comorbidities (diabetes, osteoporosis, glaucoma): use 12.5-15 mg/day 1
• Body weight is the primary factor driving response to prednisone, with an effective dose of approximately 0.19 mg/kg required for optimal response 2

The majority of patients (78-100%) respond within 7 days of initiating therapy, with symptom improvement typically occurring within the first week 2, 3. If no response occurs within 7 days at 20 mg/day, reconsider the diagnosis as this suggests an alternative condition 3.

Glucocorticoid Tapering Protocol

Follow a structured tapering schedule to minimize relapse risk while reducing cumulative steroid exposure 1:

• Weeks 0-4 to 8: Taper from initial dose to 10 mg/day 1
• After reaching 10 mg/day: Reduce by 1 mg every 4 weeks until discontinuation, provided remission is maintained 1
• Alternative tapering schemes (such as alternating 10/7.5 mg every other day) can be used during the maintenance phase 4

Management of Relapses

Relapses commonly occur when prednisone is at or below 5 mg/day 3. When relapse occurs, increase prednisone to the pre-relapse dose that effectively controlled symptoms 4:

• Gradually reduce over 4-8 weeks back to the dose at which relapse occurred 4
• Then decrease by 1 mg per month, which is slower than the initial taper 4
• For persistent nighttime pain when reducing 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:

• Specific indications include multiple or frequent relapses, high-risk factors for relapse, and risk factors for glucocorticoid adverse events 1
• Methotrexate allows for shorter prednisone treatment duration and steroid sparing, with 88% of patients able to discontinue prednisone by 76 weeks compared to 53% on prednisone alone 5
• Use with folinic acid supplementation (7.5 mg weekly) 5

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 clinical symptoms, inflammatory markers (ESR, CRP), glucocorticoid-related adverse effects, and relapse risk factors 1, 4
• Monitor for diabetes, osteoporosis, and other steroid-related complications 6

Essential Adjunctive Measures

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

• Osteoporosis prophylaxis is recommended for all patients 3
• Provide education on disease impact, treatment expectations, and comorbidity management 1
• Recommend individually tailored exercise programs 1

Common Pitfalls to Avoid

• Do not use initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect 7
• Do not use doses >30 mg/day due to increased risk of adverse effects without additional benefit 7
• Do not taper too quickly as this increases relapse risk; the 1 mg per month reduction after reaching 10 mg/day is critical 1
• Consider giant cell arteritis if symptoms are atypical or response is inadequate, as PMR is associated with this condition and may require more intense treatment 6