What is the recommended treatment approach for an older adult patient with polymyalgia rheumatica (PMR), potentially at risk for complications such as osteoporosis or diabetes due to long-term steroid use, and possibly co-occurring giant cell arteritis?

Treatment of Polymyalgia Rheumatica in Older Adults at Risk for Steroid Complications

Start with oral prednisone 12.5-25 mg daily (favoring the lower end at 12.5-15 mg in patients with diabetes or osteoporosis), and strongly consider adding methotrexate 7.5-10 mg weekly from the outset given the high risk for steroid-related complications. 1

Initial Treatment Strategy

Glucocorticoid Dosing

• Initial dose range: 12.5-25 mg prednisone equivalent daily 1
• In patients with pre-existing osteoporosis or diabetes, favor the lower end (12.5-15 mg) to minimize steroid exposure while maintaining efficacy 1
• Never exceed 30 mg daily - doses above this threshold lack evidence of benefit and carry substantial harm 1
• Expect clinical improvement within 2-4 weeks; if no response occurs, reconsider the diagnosis 1

Single Daily Dosing

• Administer as a single morning dose rather than divided doses 1
• Exception: Consider split dosing only if prominent night pain persists while tapering below 5 mg daily 1

Steroid-Sparing Strategy with Methotrexate

For patients with diabetes, osteoporosis, or other risk factors for glucocorticoid toxicity, add methotrexate 7.5-10 mg orally weekly at treatment initiation. 1

Evidence for Methotrexate

• Methotrexate significantly increases the proportion of patients who successfully discontinue prednisone (88% vs 53%) 2
• Reduces cumulative prednisone exposure by approximately 30% (2.1 g vs 2.97 g over 76 weeks) 2
• Decreases relapse rates (47% vs 73%) 2
• Preserves bone mineral density compared to prednisone alone 3

When to Add Methotrexate

• At treatment initiation in patients with diabetes, osteoporosis, hypertension, cardiovascular disease, glaucoma, or recent fractures 1
• During follow-up if relapse occurs or glucocorticoid-related adverse events develop 1
• In female patients (higher risk of steroid complications) 1

Glucocorticoid Tapering Protocol

Initial Tapering Phase (Weeks 0-8)

• Reduce from starting dose to 10 mg daily within 4-8 weeks 1
• Patients starting at higher doses (20-25 mg) can taper more rapidly initially 1
• Monitor disease activity and inflammatory markers at each reduction 1

Maintenance Tapering Phase (After reaching 10 mg)

• Reduce by 1 mg every 4 weeks until discontinuation 1, 4
• If 1 mg tablets unavailable, use alternate-day schedules (e.g., 10/7.5 mg on alternating days) 1, 4
• This slow taper minimizes relapse risk and allows adrenal axis recovery 4, 5

Managing Relapses

• Immediately return to the pre-relapse dose 1
• Maintain this dose for 4-8 weeks until disease control re-established 1
• Then gradually decrease within 4-8 weeks back to the dose at which relapse occurred 1
• Consider adding or optimizing methotrexate if not already prescribed 1

Osteoporosis Prevention

Initiate bone protection measures at treatment onset in all patients anticipated to receive ≥5 mg prednisone for ≥3 months. 5

First-Line Interventions

• Calcium and vitamin D supplementation 5
• Bisphosphonate therapy (alendronate or risedronate) 5
• Weight-bearing exercise 30-60 minutes daily 5
• Smoking cessation and alcohol limitation 5

Monitoring

• Obtain baseline bone mineral density of lumbar spine and hip 5
• Initiate bisphosphonate therapy if BMD below normal 5

Diabetes Management Considerations

Monitoring Requirements

• Check fasting glucose or HbA1c at baseline and monthly during initial treatment 5
• Anticipate worsening glycemic control requiring adjustment of diabetes medications 5

Dose Selection

• Favor lower initial prednisone doses (12.5-15 mg) in diabetic patients 1
• Consider intramuscular methylprednisolone 120 mg every 3 weeks as alternative to reduce systemic exposure 1

Screening for Giant Cell Arteritis

Evaluate all PMR patients for symptoms of giant cell arteritis at each visit, as 6-10% develop GCA during treatment. 6

Red Flag Symptoms Requiring Immediate Evaluation

• New-onset headache or change in headache pattern 7
• Visual disturbances (diplopia, blurred vision, vision loss) 7
• Jaw claudication 7
• Scalp tenderness 7
• Temporal artery abnormalities (tenderness, decreased pulse) 7

Management if GCA Develops

• Immediately increase prednisone to 40-60 mg daily 6, 7
• Arrange urgent temporal artery biopsy or vascular imaging 7
• Consider tocilizumab in addition to glucocorticoids 7

Adrenal Insufficiency Prevention

Anticipate hypothalamic-pituitary-adrenal axis suppression in any patient receiving >7.5 mg daily for >3 weeks. 5

Stress Dosing Protocol

• During acute illness or physiologic stress, double the current prednisone dose for 3 days 4
• For major stress (surgery, severe infection), use hydrocortisone 50 mg twice daily 4
• Educate patients to seek medical attention for fever or signs of infection 5
• Consider medical alert bracelet 4

Duration of Risk

• Adrenal insufficiency risk persists up to 12 months after discontinuation following prolonged therapy 5
• Maintain stress dosing precautions throughout this period 4, 5

Monitoring Schedule

Initial Phase (First 3 months)

• Clinical assessment every 2-4 weeks 1, 4
• ESR or CRP at each visit 1
• Screen for steroid adverse effects (blood pressure, glucose, weight, mood) 1, 5

Maintenance Phase

• Follow-up every 4-8 weeks during first year of tapering 4
• Then every 8-12 weeks thereafter 4
• Continue monitoring inflammatory markers and symptoms 1, 4

Common Pitfalls to Avoid

• Never start with doses >30 mg daily - no evidence of benefit and substantial harm 1
• Never taper too rapidly - most relapses occur when reducing below 5 mg daily 8
• Never ignore atypical features - peripheral arthritis, systemic symptoms, or age <60 years warrant specialist referral 1
• Never delay osteoporosis prophylaxis - bone loss begins immediately with glucocorticoid therapy 5
• Never assume good response confirms PMR - conditions mimicking PMR (malignancy, infection, inflammatory arthritis) may also respond to steroids 8, 7

Alternative: Intramuscular Methylprednisolone

Consider intramuscular methylprednisolone 120 mg every 3 weeks as alternative to oral prednisone in patients with difficult-to-control diabetes, severe osteoporosis, or glaucoma. 1

Dosing Schedule

• 120 mg every 3 weeks for weeks 0-9 1
• 100 mg at week 12, then monthly 1
• Reduce by 20 mg every 12 weeks until week 48 1
• Then reduce by 20 mg every 16 weeks until discontinuation 1

Limitations

• Supported by single randomized trial requiring confirmation 1
• Failed to demonstrate reduction in adverse events except weight gain 1
• Not available in all countries 1

Agents to Avoid

• TNF-α blocking agents: strongly contraindicated - no evidence of efficacy in PMR 1
• Chinese herbal preparations (Yanghe, Biqi capsules): strongly contraindicated 1