What's the best course of action for a patient with polymyalgia rheumatica (PMR) on 2.5 mg prednisone (corticosteroid) daily, who recently had a gout flare-up treated with colchicine (anti-gout medication), but still experiences neck pain?

Management of Persistent Neck Pain in PMR Patient on Low-Dose Prednisone

This patient's 2.5 mg prednisone dose is inadequate for polymyalgia rheumatica and should be increased to at least 12.5 mg daily to control her neck pain, which is likely a manifestation of undertreated PMR rather than a separate condition. 1

The Core Problem: Subtherapeutic Glucocorticoid Dosing

Your patient is on a dose far below the recommended therapeutic range for PMR:

• The 2015 EULAR/ACR guidelines strongly recommend against initial doses ≤7.5 mg/day for PMR 1
• The recommended initial dose range is 12.5-25 mg prednisone equivalent daily 1
• At 2.5 mg daily, she is receiving only 10-20% of the minimum recommended dose 1

The persistent neck pain is almost certainly undertreated PMR, not a separate issue. PMR characteristically affects the neck, shoulders, and hip girdle with bilateral pain and stiffness 1.

Immediate Action Plan

Step 1: Increase Prednisone Dose

• Increase prednisone to 12.5-15 mg daily immediately 1
• This lower end of the range is appropriate since she has already been on some glucocorticoid therapy 1
• Expect dramatic improvement in neck pain within 1-3 days if this is PMR (which is highly likely) 1

Step 2: Gout Management Considerations

The colchicine for her toe gout flare is appropriate and can continue:

• Continue colchicine 0.6 mg once or twice daily until the gout attack completely resolves 1
• There is no contraindication to using colchicine and prednisone together 1, 2
• In fact, glucocorticoids are a first-line option for acute gout flares and work through different mechanisms than colchicine 1

Step 3: Tapering Strategy Once Symptoms Controlled

After achieving remission of neck pain (typically within days to 2 weeks):

• Taper to 10 mg/day within 4-8 weeks 1
• Then decrease by 1 mg every 4 weeks until discontinuation, provided remission is maintained 1
• Monitor every 4-8 weeks in the first year 1

Important Caveats and Pitfalls

Common Mistake: Treating PMR with Inadequate Doses

• Many clinicians use doses that are too low, leading to persistent symptoms and patient suffering 3
• The dramatic response to adequate glucocorticoid dosing is actually a diagnostic feature of PMR 1
• If neck pain doesn't improve significantly within 1 week on 12.5-15 mg, reconsider the diagnosis 1

Drug Interaction Concerns

• Check if she's on any CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole) before continuing colchicine 2, 4
• These combinations can cause fatal colchicine toxicity 4

Renal Function Assessment

• Assess renal function before continuing colchicine 5, 4
• If CrCl <30 mL/min, colchicine should be avoided and alternative gout therapy (like the increased prednisone alone) would suffice 5, 4

Why Not Alternative Approaches?

NSAIDs Are Not Appropriate

• EULAR/ACR strongly recommends glucocorticoids over NSAIDs for PMR 1
• NSAIDs provide inadequate control of PMR symptoms 1

Don't Add Methotrexate Yet

• Methotrexate is considered only for patients with refractory disease, frequent relapses, or high risk of glucocorticoid side effects 1
• Try adequate glucocorticoid dosing first 1

Monitoring Requirements

Document at each visit: 1

• Pain level (especially neck, shoulders, hips)
• Morning stiffness duration
• Inflammatory markers (ESR/CRP)
• Glucocorticoid-related side effects (blood pressure, glucose, bone health)
• Gout flare status

Bone protection: 1

• Ensure calcium 800-1000 mg/day and vitamin D 400-800 units/day 3
• Consider bisphosphonate if prolonged therapy anticipated 1

The bottom line: Your patient needs a proper therapeutic dose of prednisone for her PMR (12.5-15 mg daily), which will likely also help with any residual gout inflammation while the colchicine continues to work. 1