What is the recommended initial treatment for a patient with symptoms of polymyalgia (muscle pain and stiffness), considering their age and potential for giant cell arteritis?

Polymyalgia Rheumatica: Initial Treatment Recommendations

Start prednisone at 12.5-25 mg daily as the initial treatment for polymyalgia rheumatica, with the specific dose within this range determined by relapse risk and comorbidity profile. 1

Immediate Treatment Initiation

• Glucocorticoids are strongly recommended over NSAIDs for disease control in PMR, as they reduce both symptoms and structural progression, whereas NSAIDs provide only symptomatic relief 1
• Clinical improvement should be noted within 2 weeks, with almost complete response expected by 4 weeks 1
• If inadequate response occurs within 2 weeks, increase the oral dose up to 25 mg prednisone equivalent 1

Dose Selection Algorithm

Higher initial dose (20-25 mg/day): 1

• Female sex (associated with higher relapse risk) 1
• High ESR (>40 mm/1st hour) 1
• Peripheral inflammatory arthritis 1
• Low risk of glucocorticoid adverse events 1

Lower initial dose (12.5-15 mg/day): 1

• Diabetes or glucose intolerance 1
• Osteoporosis or recent fractures 1
• Glaucoma or cataracts 1
• Hypertension or cardiovascular disease 1
• Peptic ulcer disease 1
• Female sex (higher risk of glucocorticoid side effects) 1

Strongly discouraged: Initial doses ≤7.5 mg/day (insufficient anti-inflammatory effect) 1

Strongly contraindicated: Initial doses >30 mg/day (no evidence of benefit, high risk of harm) 1

Critical Pre-Treatment Assessment

Before prescribing glucocorticoids, document: 1

Laboratory baseline: 1

• Rheumatoid factor and/or anti-CCP antibodies (exclude rheumatoid arthritis)
• CRP and/or ESR (typically elevated in PMR)
• Complete blood count
• Glucose and HbA1c
• Creatinine and liver function tests
• Calcium, alkaline phosphatase, vitamin D
• Urinalysis

Comorbidity screening: 1

• Hypertension, diabetes, cardiovascular disease
• Dyslipidemia, peptic ulcer disease
• Osteoporosis (consider DEXA scan)
• Glaucoma risk factors, cataracts
• Chronic or recurrent infections
• Current NSAID use

Glucocorticoid Tapering Protocol

Initial tapering (weeks 0-8): 1

• Reduce dose gradually to 10 mg/day prednisone equivalent within 4-8 weeks
• Use single daily dosing (morning preferred) rather than divided doses 1

Maintenance tapering (after week 8): 1

• Once remission is achieved, taper by 1 mg every 4 weeks until discontinuation
• Alternative schedules (e.g., 10/7.5 mg alternate days) are acceptable if 1 mg tablets unavailable 1

Relapse management: 1

• Increase dose to the pre-relapse effective dose
• Decrease gradually within 4-8 weeks back to the dose at which relapse occurred
• Then resume slow taper by 1 mg every 4 weeks 1

Alternative Glucocorticoid Formulation

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

• Starting dose: 120 mg IM every 3 weeks for first 9 weeks 1
• Consider in patients with difficult-to-control hypertension, diabetes, osteoporosis, or glaucoma where lower cumulative glucocorticoid exposure is desirable 1
• Evidence is limited to a single randomized trial; long-term benefit unclear 1

Adjunctive Methotrexate Therapy

Consider early introduction of methotrexate (7.5-10 mg/week orally) in addition to glucocorticoids for: 1

• High risk of relapse (female sex, high ESR, peripheral arthritis) 1
• Risk factors for glucocorticoid-related adverse events 1
• Patients experiencing relapse during glucocorticoid taper 1
• Methotrexate may reduce cumulative glucocorticoid dosage by 20-44% and relapses by 36-54% 2

Monitoring Schedule

First year: Every 4-8 weeks 1

Second year: Every 8-12 weeks 1

At each visit, assess: 1

• Disease activity (pain, stiffness, functional impairment)
• Inflammatory markers (CRP/ESR)
• Glucocorticoid-related side effects (weight, blood pressure, glucose, bone health)
• Evidence of relapse

Giant Cell Arteritis Screening

Refer immediately for specialist evaluation if: 1

• New-onset headache, particularly temporal headache 3, 4
• Visual disturbances or vision loss 3, 4
• Jaw claudication 3, 4
• Scalp tenderness 3, 4
• Temporal artery abnormalities (tenderness, decreased pulse) 3, 4

Giant cell arteritis occurs in approximately 20% of PMR patients and requires higher glucocorticoid doses (40-60 mg/day prednisone) to prevent irreversible vision loss 5, 4

Specialist Referral Indications

Consider rheumatology referral for: 1

• Age <60 years 1
• Peripheral inflammatory arthritis 1
• Low or normal inflammatory markers 1
• Systemic symptoms beyond typical PMR 1
• High risk of glucocorticoid-related side effects 1
• Inadequate response to initial therapy within 2 weeks 1
• Frequent relapses or prolonged therapy requirement 1

Glucocorticoid-Related Prophylaxis

Mandatory for all patients: 1

• Calcium and vitamin D supplementation if prednisone >7.5 mg/day for >3 months 1
• Consider bisphosphonate therapy based on bone mineral density and fracture risk 1
• Proton pump inhibitor if concurrent NSAID use 1