What is the recommended treatment for a patient with Polymyalgia Rheumatica (PMR)?

Treatment of Polymyalgia Rheumatica

Initial Glucocorticoid Therapy

Start prednisone at 12.5-25 mg daily, with the specific dose determined by body weight, relapse risk factors, and comorbidity profile. 1, 2

Dose Selection Algorithm

• Use 20-25 mg/day for patients with high relapse risk (female sex, ESR >40 mm/hr, peripheral arthritis) AND low risk of glucocorticoid adverse events 1
• Use 12.5-15 mg/day for patients with relevant comorbidities including diabetes, osteoporosis, or glaucoma 1, 2
• Body weight is the primary determinant of response: patients requiring approximately 0.19 mg/kg respond successfully, while those receiving 0.16 mg/kg often fail initial therapy 3
• Strongly avoid initial doses ≤7.5 mg/day (insufficient anti-inflammatory effect) and strongly avoid doses >30 mg/day (increased adverse effects without additional benefit) 4, 2

Alternative Route

• Intramuscular methylprednisolone 120 mg every 3 weeks can be considered as an alternative to oral glucocorticoids, particularly for patients with adherence concerns or gastrointestinal intolerance 4, 2

Glucocorticoid Tapering Protocol

Taper prednisone to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation, provided remission is maintained. 4, 1, 2

Specific Tapering Steps

• Initial tapering phase (weeks 0-8): Reduce from starting dose to 10 mg/day 4, 1
• Maintenance tapering phase: Decrease by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg on alternating days where 1 mg tablets are unavailable) 4, 2
• For prominent nighttime pain when tapering below 5 mg/day: Consider splitting the daily dose rather than single morning dosing 2

The evidence strongly supports slow tapering (<1 mg/month) over faster regimens, as this approach reduces relapse frequency and increases successful glucocorticoid discontinuation 5. A prolonged period at 5 mg/day before further tapering may result in lower total cumulative glucocorticoid doses 6.

Management of Relapses

For relapse, increase prednisone to the pre-relapse dose, then taper gradually over 4-8 weeks back to the dose at which relapse occurred, followed by reduction of 1 mg per month. 1, 2

• After re-establishing disease control, the subsequent taper must be slower than the initial reduction schedule 2
• Relapses are more common with starting doses below 15 mg/day and with rapid tapering regimens 5

Glucocorticoid-Sparing Therapy with Methotrexate

Add methotrexate 7.5-10 mg weekly for patients with frequent relapses, prolonged therapy requirements, or significant glucocorticoid-related adverse effects. 4, 1, 2

Specific Indications for Methotrexate

• Multiple or frequent relapses during glucocorticoid tapering 1, 2
• High-risk factors for relapse (female sex, ESR >40, peripheral arthritis) 1
• Risk factors for glucocorticoid adverse events (diabetes, osteoporosis, hypertension, glaucoma) 4, 2
• Inadequate response to glucocorticoids alone 2
• Patients experiencing glucocorticoid-related adverse events 2

Methotrexate at doses of 10 mg/week or higher demonstrates glucocorticoid-sparing properties, though lower doses (7.5 mg/week) have also been used in clinical trials 4, 5.

Medications to Avoid

• TNFα blocking agents (such as infliximab) are strongly contraindicated for PMR treatment, as they have proven ineffective 4, 2
• Chinese herbal preparations Yanghe and Biqi capsules should not be used 4, 2

Monitoring and Follow-Up Schedule

Schedule visits every 4-8 weeks during the first year, every 8-12 weeks in the second year, and as needed for relapses or dose adjustments. 1, 2

At Each Visit Assess

• Clinical symptoms (pain, stiffness, functional status) 1, 2
• Inflammatory markers (ESR, CRP) 4, 2
• Glucocorticoid-related adverse effects 1, 2
• Risk factors for relapse 1

Essential Adjunctive Measures

Initiate bone protection at treatment start with calcium and vitamin D supplementation, and assess bone mineral density for bisphosphonate consideration. 1, 2

• All patients on chronic glucocorticoids require osteoporosis prophylaxis, as prednisone causes significant bone loss 1, 2
• Consider bisphosphonate therapy particularly for patients with prior fractures or anticipated prolonged treatment 2
• Provide individually tailored exercise programs aimed at maintaining muscle mass and function, and reducing fall risk in older patients on long-term glucocorticoids 4, 1

Common Pitfalls to Avoid

• Starting with insufficient doses based on fixed protocols rather than body weight can lead to treatment failure 3
• Tapering too rapidly (>1 mg/month) significantly increases relapse risk 5
• Failing to add methotrexate early in high-risk patients results in prolonged glucocorticoid exposure and cumulative adverse effects 4, 7
• Patients requiring doses >30 mg/day should be evaluated for alternative diagnoses rather than continuing high-dose therapy 4