What is the recommended treatment for polymyalgia rheumatica (PMR) in older adults?

Treatment of Polymyalgia Rheumatica in Older Adults

Start prednisone at 12.5-25 mg daily immediately upon diagnosis, with the specific dose individualized based on relapse risk factors and comorbidity burden. 1, 2

Initial Glucocorticoid Dosing Strategy

The cornerstone of PMR treatment is oral glucocorticoids, with the initial dose selection critical for balancing efficacy and safety:

For patients with high relapse risk and low comorbidity burden:

• Use prednisone 20-25 mg/day 2
• High relapse risk includes: female sex, ESR >40 mm/hr, peripheral arthritis 2

For patients with significant comorbidities:

• Use prednisone 12.5-15 mg/day 2
• Relevant comorbidities include: diabetes, osteoporosis, glaucoma, or other glucocorticoid-sensitive conditions 1, 2

Doses to avoid:

• Strongly avoid initial doses >30 mg/day due to increased adverse effects without additional benefit 1
• Discourage doses ≤7.5 mg/day as insufficient for initial disease control 1

The evidence consistently shows that starting doses of 15 mg/day achieve remission in most patients, while higher doses (>15 mg/day) increase glucocorticoid-related adverse effects without improving long-term outcomes 3. Single daily dosing is preferred over divided doses, except when prominent nighttime pain occurs during tapering below 5 mg/day 1, 4.

Glucocorticoid Tapering Protocol

Initial taper phase (first 4-8 weeks):

• Reduce prednisone to 10 mg/day within 4-8 weeks if remission is achieved 1, 2

Maintenance taper phase:

• Once at 10 mg/day, reduce by 1 mg every 4 weeks until discontinuation 1, 2
• In countries without 1 mg tablets, use alternate-day dosing (e.g., 10/7.5 mg on alternating days) 1

Critical principle: Slow tapering (<1 mg/month) below 10 mg/day reduces relapse rates and increases likelihood of successful glucocorticoid cessation compared to faster tapering 3. The typical treatment duration is 2-3 years, though some patients require longer therapy 5.

Management of Relapses

Relapses are common, particularly when prednisone is tapered to ≤5 mg/day 6:

For relapse occurring:

• Increase prednisone back to the pre-relapse dose that controlled symptoms 4, 2
• Re-establish remission, then taper over 4-8 weeks back to the dose at which relapse occurred 4, 2
• Subsequently reduce by 1 mg per month (slower than initial taper) 4, 2

Glucocorticoid-Sparing Agents

Methotrexate (7.5-10 mg weekly) should be added for: 1, 2

• Patients with frequent or multiple relapses 1, 2
• Those requiring prolonged glucocorticoid therapy 2
• Patients experiencing significant glucocorticoid-related adverse effects 1, 2

Methotrexate at doses ≥10 mg/week demonstrates glucocorticoid-sparing efficacy, reducing cumulative glucocorticoid exposure and relapse frequency 1, 3.

IL-6 receptor blocking agents (tocilizumab, sarilumab):

• Consider for relapsing disease despite methotrexate 7, 8
• May be considered in new-onset PMR with high risk for glucocorticoid adverse events 8
• These biologics reduce relapse frequency, lower cumulative glucocorticoid burden, and achieve long-term remission 7

Agents to avoid:

• TNF-α blocking agents are strongly recommended against—they are ineffective in isolated PMR 1, 7

Alternative Glucocorticoid Formulations

Intramuscular methylprednisolone may be considered as an alternative to oral glucocorticoids 1:

• Dosing: 120 mg IM every 3 weeks until week 9, then 100 mg at week 12, followed by monthly injections with gradual dose reduction 1
• This route may be useful for patients with adherence issues or gastrointestinal intolerance, though evidence is limited 1

Essential Adjunctive Measures

Bone protection must be initiated at treatment start: 2

• Prednisone causes significant bone loss in this elderly population 2
• Implement calcium, vitamin D supplementation, and consider bisphosphonates based on fracture risk 2

Exercise program: 1, 2

• Offer individually tailored exercise programs aimed at maintaining muscle mass and function 1
• Particularly important for reducing fall risk in older persons on long-term glucocorticoids 1

Monitoring Schedule

First year: Visit every 4-8 weeks 2 Second year: Visit every 8-12 weeks 2 At each visit, assess: 2

• Clinical symptoms and inflammatory markers (ESR, CRP) 2
• Glucocorticoid-related adverse effects 2
• Risk factors for relapse 2

Common Pitfalls to Avoid

• Starting too high (>30 mg/day): Increases adverse effects without improving outcomes 1
• Tapering too quickly: Rates >1 mg/month below 10 mg/day increase relapse risk 3
• Delaying methotrexate: Add early in patients with relapse risk factors rather than waiting for multiple relapses 1, 2
• Forgetting bone protection: Osteoporosis prophylaxis is not optional in this elderly population on chronic glucocorticoids 2, 6
• Requiring high doses (>30 mg/day): This should prompt evaluation for alternative diagnoses, not continuation of high-dose therapy 1