What is the recommended management of a polymyalgia rheumatica flare in a patient over 65 years old who is on low-dose oral prednisone, including glucocorticoid dose adjustment, assessment for giant cell arteritis, and use of steroid-sparing agents?

Management of Polymyalgia Rheumatica Flare

For a PMR flare in a patient over 65 on low-dose prednisone, immediately increase prednisone to the pre-relapse dose that previously controlled symptoms, maintain for 4-8 weeks, then taper more slowly than before at 1 mg every 4 weeks. 1, 2

Immediate Glucocorticoid Dose Adjustment

Return to the previous effective dose that controlled symptoms before the flare occurred. 1, 2 This is typically the dose the patient was taking before the most recent reduction that triggered the relapse.

• Maintain this increased dose for 4-8 weeks until disease control is re-established and inflammatory markers normalize 1, 2
• After achieving remission, gradually reduce over 4-8 weeks back down to the dose at which the relapse occurred 1, 2
• Once at the relapse dose, proceed with a slower taper than initially attempted: decrease by only 1 mg every 4 weeks (not faster) 1, 2

For patients who flared on ≤5 mg prednisone: Consider using alternating-day dosing schemes (such as 10/7.5 mg on alternate days) to achieve gradual 1 mg monthly reductions if 1 mg tablets are unavailable. 1, 2 If nighttime pain is prominent at these low doses, splitting the daily dose into morning and evening administration is acceptable. 1, 2

Assessment for Giant Cell Arteritis

Screen every PMR flare patient for new GCA symptoms, as 16-21% of PMR patients develop GCA during their disease course. 3

Critical red flags requiring immediate evaluation:

• New-onset headache (especially temporal or occipital) 3
• Visual disturbances or sudden vision loss 3
• Jaw claudication (pain with chewing) 3
• Scalp tenderness 3
• Temporal artery tenderness, nodularity, or absent pulse 3

If any GCA symptoms are present: Immediately escalate to high-dose glucocorticoids (prednisone 40-60 mg daily) before confirming diagnosis, as untreated GCA can cause irreversible blindness. 4, 3 Arrange urgent temporal artery biopsy or color duplex ultrasonography within 1-2 weeks. 3

Monitoring During Flare Management

Check inflammatory markers monthly during the dose adjustment phase:

• Erythrocyte sedimentation rate (ESR) 2, 3
• C-reactive protein (CRP) 2, 3

Follow-up visits every 4-8 weeks during the first year after a flare to monitor for:

• Disease activity and symptom control 2
• Glucocorticoid-related adverse effects 2
• Signs of repeat relapse 2

Steroid-Sparing Agents

Consider adding methotrexate for patients with multiple relapses (≥2 flares) or those unable to taper below 7.5-10 mg prednisone without relapsing. 2, 5, 3

• Methotrexate dosing: 7.5-15 mg weekly (oral or subcutaneous) 5
• Evidence shows modest glucocorticoid-sparing benefit, reducing cumulative prednisone exposure by approximately 20-30% 5
• Allow 6-12 weeks for methotrexate to reach therapeutic effect before attempting accelerated prednisone taper 1

Once methotrexate is established (after 2-3 months): You can taper prednisone more aggressively—reduce by 5 mg weekly until reaching 10 mg/day, then by 2.5 mg every 2-4 weeks. 1 Monitor liver enzymes monthly during this phase. 1

Tocilizumab (IL-6 inhibitor) is emerging as a promising option for refractory cases but is not yet FDA-approved for PMR (only for GCA). 5, 6, 3 Reserve for patients failing methotrexate or with contraindications to prolonged glucocorticoids.

Bone Protection

Initiate or continue bisphosphonate therapy in all PMR patients over 65 requiring glucocorticoid dose escalation. 7

• Alendronate 70 mg weekly is the standard prophylaxis against glucocorticoid-induced osteoporosis 7
• This population (elderly, female predominance, prolonged glucocorticoid exposure) is at extremely high risk for fractures 7
• Bone loss occurs rapidly with glucocorticoids; do not delay prophylaxis 7

Common Pitfalls to Avoid

Tapering too quickly after flare resolution is the most frequent error—the 1 mg per month reduction is a maximum rate, not a minimum. 1, 2 Slower tapering (1 mg every 6-8 weeks) may be necessary for patients with multiple prior relapses.

Failing to recognize GCA overlap—always ask about headache, vision changes, and jaw claudication at every visit, as GCA can develop at any point during PMR treatment. 3

Delaying steroid-sparing agents—if a patient has had 2 or more flares, methotrexate should be started rather than continuing repeated cycles of prednisone escalation. 2, 3

Inadequate bone protection—elderly PMR patients on chronic glucocorticoids universally need bisphosphonate prophylaxis unless contraindicated. 7