Initial Treatment of Polymyalgia Rheumatica
Start prednisone at 12.5-25 mg daily as initial therapy for PMR, with most patients responding within 7 days. 1
Recommended Initial Glucocorticoid Dosing
The European League Against Rheumatism/American College of Rheumatology guidelines establish a clear dosing framework:
- Use 12.5-25 mg prednisone equivalent daily as the initial dose range 1
- Within this range, tailor the specific dose based on individual risk factors 1:
- Strongly avoid initial doses >30 mg/day due to excessive adverse effects 1
- Discourage initial doses ≤7.5 mg/day as they provide insufficient anti-inflammatory effect 1, 2
Research supports that starting doses of 15 mg/day achieve remission in most patients while minimizing cumulative glucocorticoid exposure 3. Doses of 10-20 mg/day yield clinical improvement within 7 days in the majority of patients 4.
Why Glucocorticoids Over NSAIDs
Glucocorticoids are strongly recommended instead of NSAIDs for PMR treatment 1. NSAIDs may only be used short-term for pain related to other conditions, not for PMR disease control 1. This distinction is critical because glucocorticoids address the underlying inflammatory process, while NSAIDs provide only symptomatic relief 5.
Initial Tapering Schedule
After starting treatment, follow this structured approach:
- Taper to 10 mg/day within 4-8 weeks if symptoms are controlled 1
- Once at 10 mg/day, reduce by 1 mg every 4 weeks (or use alternating schedules like 10/7.5 mg on alternate days) 1
- Continue tapering until discontinuation, typically over 2-3 years total 6
- Slower tapering (<1 mg/month) below 10 mg/day reduces relapse rates compared to faster reduction 3
Monitoring Requirements
Establish regular follow-up to assess response and adverse effects:
- Every 4-8 weeks during the first year 1
- Every 8-12 weeks in the second year 1
- At each visit, document disease activity, inflammatory markers (ESR/CRP), and glucocorticoid-related adverse effects 1
- Screen for comorbidities including hypertension, diabetes, osteoporosis, glaucoma, and infections 1
Expected Response and Red Flags
Dramatic improvement within 7 days is typical for PMR 4. If a patient fails to respond adequately to 20 mg/day prednisone within this timeframe, strongly consider alternative diagnoses 4:
- Giant cell arteritis (occurs in ~20% of PMR cases) 6
- Elderly-onset rheumatoid arthritis (frequently misdiagnosed as PMR) 6, 7
- Malignancy, infection, or endocrine disorders 7
Atypical features warranting specialist referral include peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, or age <60 years 1.
Managing Relapses
Relapses are common, occurring in approximately 50% of patients during tapering, particularly at doses ≤5 mg/day 4, 7:
- Increase prednisone to the pre-relapse dose 1, 8
- Gradually decrease over 4-8 weeks back to the dose where relapse occurred 1, 8
- Then taper more slowly than initially, not exceeding 1 mg per month 8
- For frequent relapses, consider adding methotrexate as a glucocorticoid-sparing agent 8, 4
Adjunctive Measures
All patients require:
- Osteoporosis prophylaxis with calcium and vitamin D supplementation 4
- Assessment of cardiovascular risk factors and dyslipidemia 1
- Patient education on disease course and self-monitoring 1
- Direct access to healthcare providers for reporting flares or adverse events 1
Long-Term Considerations
PMR is not always time-limited—approximately 40% of patients remain on glucocorticoids beyond 5 years 9. Patients who are older, live alone, or have sustained symptoms are at higher risk for prolonged treatment 9. This underscores the importance of using the minimum effective dose and considering steroid-sparing agents like methotrexate (≥10 mg/week) for those requiring prolonged therapy 3.