How can we safely increase steroids in a patient with a history of Polymyalgia Rheumatica (PMR) and gout, currently on 2.5mg of prednisone, to manage her neck pain?

Managing Steroid Increase in PMR Patient on Low-Dose Prednisone

For a patient with PMR currently on 2.5 mg prednisone experiencing neck pain, increase prednisone to the previous dose that controlled symptoms (likely 5-7.5 mg daily), then taper slowly by 1 mg every 4 weeks once remission is re-established. 1

Approach to Steroid Increase for Relapse

Treat this as a PMR relapse requiring temporary dose escalation:

• Return to the pre-relapse dose that previously controlled symptoms effectively—this is typically the last dose where the patient was symptom-free 2, 1
• If uncertain about the previous effective dose, increase to 5 mg daily as a reasonable starting point for patients relapsing at very low doses 1
• Once symptoms are controlled (typically within days to 2 weeks), gradually reduce over 4-8 weeks back to 2.5 mg 2, 1
• After reaching 2.5 mg again, taper more slowly than before—reduce by only 1 mg every 4 weeks (or use alternating schedules like 2.5/1.25 mg on alternate days) 2, 3

Why This Approach is Safe Despite Comorbidities

The temporary increase is justified because:

• PMR requires adequate glucocorticoid dosing to control inflammation; undertreating leads to prolonged disease activity and potentially higher cumulative steroid exposure 2, 4
• Initial doses ≤7.5 mg/day are discouraged by EULAR/ACR as they provide insufficient anti-inflammatory effect 4
• A brief increase to 5-7.5 mg is far safer than the initial treatment range of 12.5-25 mg daily 4
• For gout history: adequate PMR control actually reduces overall inflammatory burden, and short-term modest prednisone increases (5-7.5 mg) are unlikely to trigger gout flares

Monitoring During Dose Adjustment

Schedule follow-up every 4 weeks during this adjustment period: 2, 3

• Assess clinical symptoms (shoulder/hip girdle pain, morning stiffness duration)
• Check inflammatory markers (ESR/CRP) to confirm disease control 3
• Monitor for steroid-related adverse effects (blood glucose, blood pressure, bone health) 2
• Document the lowest effective dose achieved 2

Consider Methotrexate as Steroid-Sparing Agent

If this is a second relapse or the patient cannot taper below 5 mg without symptoms:

• Add methotrexate 7.5-10 mg weekly to allow lower prednisone doses 2, 3, 5
• Methotrexate is specifically indicated for patients with frequent relapses, prolonged therapy requirements, or those at high risk for glucocorticoid adverse events (which applies given gout history) 2, 3
• Evidence shows methotrexate allows 34% more patients to discontinue prednisone compared to prednisone alone 5

Adjunctive Pain Management

For breakthrough neck pain specifically:

• Tramadol is reasonable for additional pain control as you mentioned, since it addresses pain without interfering with PMR treatment 2
• Physical therapy is appropriate and recommended by EULAR for maintaining muscle mass and function 2
• However, NSAIDs should not replace glucocorticoids for PMR treatment—they only provide symptomatic relief without addressing underlying inflammation 2, 4

Timing and Administration

Optimize steroid dosing schedule:

• Administer the entire daily prednisone dose as a single morning dose before 9 AM to minimize HPA axis suppression 6
• Take with food to reduce gastric irritation 6
• Exception: if prominent nighttime pain persists when tapering below 5 mg daily, consider splitting the dose 2, 1

Common Pitfall to Avoid

Do not maintain 2.5 mg indefinitely if symptoms are not controlled—this leads to smoldering inflammation and poor quality of life while still exposing the patient to steroid side effects. Adequate disease control with appropriate dosing followed by slow taper is superior to chronic underdosing. 2, 4