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/day) for patients at high relapse risk and lower doses (12.5-15 mg/day) for those with diabetes, osteoporosis, or glaucoma. 1

Initial Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis by verifying:

• Age ≥60 years (younger patients require specialist referral for atypical presentation) 1
• Bilateral shoulder and hip girdle pain with morning stiffness >45 minutes 1
• Elevated inflammatory markers (ESR >40 mm/hr or elevated CRP) 1
• Dramatic response to glucocorticoids within 7 days (lack of response should prompt reconsideration of diagnosis) 2

Starting Dose Selection Algorithm

For patients with high relapse risk and low adverse event risk:

• Use prednisone 20-25 mg/day 1
• High-risk features include female sex, ESR >40, and peripheral arthritis 1

For patients with relevant comorbidities:

• Use prednisone 12.5-15 mg/day 1
• Comorbidities include diabetes, osteoporosis, and glaucoma 1

Weight-based dosing consideration:

• The optimal dose correlates with body weight at approximately 0.19 mg/kg 3
• Lower-weight patients (particularly women) may respond adequately to 12.5 mg daily 3

The evidence strongly supports that starting doses of 15 mg/day achieve remission in most patients while minimizing cumulative glucocorticoid exposure 4. Starting doses >15 mg/day are associated with more glucocorticoid-related adverse effects without additional benefit 4.

Glucocorticoid Tapering Protocol

Initial taper (first 4-8 weeks):

• Reduce prednisone to 10 mg/day within 4-8 weeks 1

Maintenance taper:

• Decrease by 1 mg every 4 weeks until discontinuation, provided remission is maintained 1
• Slow tapering (<1 mg/month) is associated with fewer relapses and more frequent treatment cessation compared to faster regimens 4

Common pitfall: Tapering faster than 1 mg/month below 10 mg/day significantly increases relapse risk 4. If persistent nighttime pain occurs when reducing below 5 mg/day, consider splitting the daily dose 5.

Management of Relapses

For relapse during tapering:

• Increase prednisone back to the pre-relapse dose 1, 5
• Taper more slowly over 4-8 weeks back to the dose at which relapse occurred 1, 5
• Then reduce by 1 mg per month 1, 5

For patients relapsing on ≤5 mg prednisone:

• Return to the previous dose that effectively controlled symptoms 5
• Subsequent reduction should not exceed 1 mg per month 5

Glucocorticoid-Sparing Agents

Add methotrexate 7.5-10 mg weekly for:

• Multiple or frequent relapses 1, 5
• Prolonged therapy requirements 1
• Significant glucocorticoid-related adverse effects 1
• High-risk factors for relapse 1

Methotrexate demonstrates glucocorticoid-sparing properties at doses ≥10 mg/week 4. This is the most commonly used corticosteroid-sparing agent in PMR 2.

Emerging biologic options:

• Anti-IL-6 receptor agents (tocilizumab and sarilumab) have demonstrated efficacy in reducing relapse frequency and cumulative glucocorticoid burden 6
• These should be considered for refractory cases, though cost and availability may limit use 6
• Anti-TNF agents have failed to show benefit in isolated PMR 6

Monitoring Schedule

First year:

• Schedule visits every 4-8 weeks 1, 5

Second year:

• Schedule visits every 8-12 weeks 1

At each visit, assess:

• Clinical symptoms and inflammatory markers (ESR, CRP) 1, 5
• Glucocorticoid-related adverse effects 1, 5
• Risk factors for relapse 1, 5

Essential Adjunctive Measures

Bone protection:

• Initiate at treatment start, as prednisone causes significant bone loss 1
• Osteoporosis prophylaxis is recommended for all patients 2

Patient education:

• Provide education on disease impact, treatment expectations, and comorbidity management 1
• Recommend individually tailored exercise programs 1

Critical Pitfalls to Avoid

• Starting doses >15 mg/day increase adverse effects without improving outcomes 4
• Tapering faster than 1 mg/month below 10 mg/day dramatically increases relapse risk 4
• Failure to respond to 20 mg/day prednisone within 7 days should prompt reconsideration of the diagnosis 2
• Relapses are most common when prednisone dose is ≤5 mg/day, requiring vigilant monitoring during this phase 2