What is the recommended treatment for a patient diagnosed with polymyalgia rheumatica (PMR), considering their overall health and potential for long-term steroid use complications?

Treatment of Polymyalgia Rheumatica

Start prednisone at 12.5-25 mg daily (not NSAIDs), taper to 10 mg within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation, and consider adding methotrexate 7.5-10 mg weekly for patients at high risk of relapse or steroid complications. 1

Initial Glucocorticoid Dosing Strategy

Glucocorticoids are the only disease-modifying treatment for PMR and must be used instead of NSAIDs, which provide only symptomatic relief without addressing the underlying inflammatory process. 1

Dose Selection Based on Risk Factors

• Use 20-25 mg prednisone daily for patients at high risk of relapse (female sex, ESR >40 mm/hr, peripheral inflammatory arthritis) who have low risk of adverse events 1, 2
• Use 12.5-15 mg prednisone daily for patients with diabetes, osteoporosis, glaucoma, hypertension, cardiovascular disease, or other glucocorticoid-related risk factors 1, 2
• Body weight matters: The effective dose is approximately 0.19 mg/kg, meaning lighter patients may respond to lower doses within the 12.5-25 mg range 3
• Never exceed 30 mg daily as initial dose—this provides no additional benefit and significantly increases adverse effects 1
• Avoid doses ≤7.5 mg daily as they provide insufficient anti-inflammatory effect 1, 2

Expected Response Timeline

• Most patients respond within 7 days, with dramatic improvement in symptoms 2
• If no response within 2-4 weeks at appropriate dosing, reconsider the diagnosis—patients requiring high doses should be evaluated for alternate diagnoses such as rheumatoid arthritis, inflammatory myositis, or malignancy 1

Tapering Protocol

Phase 1: Initial Taper (Weeks 1-8)

• Reduce from starting dose to 10 mg daily within 4-8 weeks if symptoms are controlled and inflammatory markers normalize 1, 2
• Use single daily morning dosing rather than divided doses (exception: prominent night pain when below 5 mg daily may warrant split dosing) 1

Phase 2: Slow Taper (After Week 8)

• Once at 10 mg daily, reduce by 1 mg every 4 weeks until discontinuation, provided remission is maintained 1, 2
• Alternative schedules like alternating 10/7.5 mg on alternate days can be used where 1 mg tablets are unavailable 1
• Total treatment duration typically ranges 12-24 months, with mean cumulative doses of 1.8-3.0 grams when properly managed 4, 5

Managing Relapses During Taper

• Increase prednisone back to the pre-relapse dose immediately 1, 2
• Taper more slowly than initially: reduce over 4-8 weeks back to the dose where relapse occurred, then continue tapering at 1 mg every 4 weeks 1
• Consider adding methotrexate at this point if not already prescribed 1

Methotrexate as Steroid-Sparing Agent

Add methotrexate 7.5-10 mg weekly (with folic acid supplementation) early in treatment for patients at high risk of relapse, those with comorbidities making prolonged steroids dangerous, or those experiencing relapses. 1

Evidence Supporting Methotrexate

• Methotrexate significantly increases the proportion of patients who successfully discontinue prednisone: 88% vs 53% at 76 weeks 4
• Reduces flare-ups: 47% vs 73% experienced at least one flare-up 4
• Lowers cumulative steroid burden: median 2.1 grams vs 2.97 grams 4
• Preserves bone mineral density compared to prednisone alone, critical in elderly patients at high fracture risk 6

When to Consider Methotrexate

• At diagnosis for patients with diabetes, osteoporosis, glaucoma, or cardiovascular disease 1
• At diagnosis for female patients or those with ESR >40 mm/hr (higher relapse risk) 1
• During follow-up for patients experiencing relapses or unable to taper below 10 mg daily 1
• During follow-up for patients experiencing steroid-related adverse events 1

Alternative Glucocorticoid Formulation

• Intramuscular methylprednisolone 120 mg every 3 weeks can be considered as an alternative to oral prednisone, particularly for patients with adherence issues or gastrointestinal intolerance 1
• This approach may reduce overall glucocorticoid exposure but has less robust evidence than oral therapy 1

Monitoring Requirements

Visit Schedule

• Every 4-8 weeks during the first year to assess disease activity, inflammatory markers (ESR/CRP), and adverse effects 1, 2
• Every 8-12 weeks during the second year 1
• Provide direct access to healthcare providers between visits for reporting flares or adverse events 1, 2

Essential Assessments at Each Visit

• Disease activity: shoulder and hip girdle pain, morning stiffness duration 1, 2
• Laboratory markers: ESR and CRP to confirm remission 1, 2
• Steroid-related complications: blood pressure, blood glucose, bone density (baseline and annually), ocular examination for cataracts/glaucoma 1, 2
• Cardiovascular risk factors: lipid profile, weight, signs of fluid retention 1, 2

Adjunctive Measures

Bone Protection (Mandatory)

• Calcium and vitamin D supplementation for all patients on glucocorticoids 1
• Bisphosphonates should be considered for patients with osteoporosis or high fracture risk 1

Exercise Program

• Individualized exercise program to maintain muscle mass and function, reduce fall risk in older patients on long-term steroids 1

Patient Education

• Educate patients on expected disease course, importance of adherence, and self-monitoring for flares 2, 7
• Explain that symptoms may partially return during taper, especially in the latter part of the day when on alternate-day regimens 8

Treatments to Avoid

• Never use TNF-α blocking agents (etanercept, adalimumab, infliximab) for isolated PMR—they are ineffective 1
• Avoid Chinese herbal preparations (Yanghe and Biqi capsules) 1
• Do not use NSAIDs as primary therapy—reserve only for short-term pain relief from other conditions (e.g., osteoarthritis) 1

Common Pitfalls

• Starting dose too high (>30 mg): Increases adverse effects without improving outcomes 1
• Starting dose too low (≤7.5 mg): Provides inadequate disease control 1, 2
• Tapering too rapidly: Increases relapse risk—stick to 1 mg every 4 weeks once below 10 mg daily 1
• Failing to consider methotrexate early: Waiting until multiple relapses occur misses opportunity to reduce cumulative steroid burden 1, 4
• Not adjusting for body weight: Lighter patients may need lower end of dosing range (12.5 mg), heavier patients may need higher end (20-25 mg) 3

Emerging Therapies

IL-6 receptor antagonists (tocilizumab, sarilumab) show promise for reducing relapse frequency and achieving long-term remission in refractory cases, though they are not yet standard therapy and cost considerations apply 9