Management of Polymyalgia Rheumatica in a 72-Year-Old Woman
Start prednisone 12.5–25 mg daily (favoring 15–20 mg for this patient given her age and sex), taper to 10 mg by week 4–8, then reduce by 1 mg every 4 weeks until discontinuation, while initiating calcium/vitamin D supplementation and bisphosphonate therapy for osteoporosis prophylaxis, and monitoring closely for giant cell arteritis symptoms at every visit. 1
Initial Glucocorticoid Dosing
Begin with prednisone 15–20 mg daily for this 72-year-old woman, as the EULAR/ACR guidelines recommend an individualized dose within the 12.5–25 mg range based on risk stratification. 1
Female sex increases both relapse risk and glucocorticoid-related adverse events, which creates a clinical tension: she needs adequate initial dosing to control disease but faces higher complication rates. 1, 2
Her elevated ESR and CRP support the diagnosis and should be documented as baseline values for monitoring. 1, 2
Doses below 7.5 mg daily are discouraged, and doses above 30 mg daily are strongly contraindicated for PMR (reserving higher doses for giant cell arteritis). 1
Expect dramatic clinical improvement within 2 weeks; if symptoms do not substantially improve, increase the dose up to 25 mg or reconsider the diagnosis. 1, 3
Glucocorticoid Tapering Protocol
Initial Taper (Weeks 0–8)
- Reduce prednisone from the starting dose to 10 mg daily over 4–8 weeks if clinical remission is achieved (resolution of pain and stiffness, normalization of inflammatory markers). 1
Maintenance Taper (After Week 8)
Once at 10 mg daily, decrease by 1 mg every 4 weeks (or use alternate-day schedules like 10/7.5 mg to achieve 1.25 mg decrements) until complete discontinuation. 1
Monitor at every dose reduction for recurrence of symptoms or inflammatory marker elevation. 1
Relapse Management
If relapse occurs during tapering, increase prednisone back to the pre-relapse dose (the last dose at which she was symptom-free), then taper again over 4–8 weeks to the dose where relapse occurred. 1
High baseline ESR (>40 mm/hour) predicts higher relapse rates, which this patient has, necessitating vigilant monitoring. 1, 2
Osteoporosis Prophylaxis
Mandatory Interventions
Initiate calcium 1200–1500 mg daily and vitamin D 800–1000 IU daily immediately upon starting glucocorticoids. 1, 2
Start bisphosphonate therapy (alendronate 70 mg weekly or risedronate 35 mg weekly) for fracture prevention, as she is a postmenopausal woman starting prolonged glucocorticoid therapy. 1, 2
Baseline Assessment
Obtain baseline bone density (DEXA scan) if not done recently, along with baseline bone profile (calcium, alkaline phosphatase). 2
Female patients have higher risk of glucocorticoid-induced osteoporosis, making prophylaxis non-negotiable. 1, 2
Monitoring for Giant Cell Arteritis
Critical Warning Symptoms
Educate the patient to report immediately: new-onset headache, visual changes (blurred vision, diplopia, sudden vision loss), jaw claudication (pain with chewing), scalp tenderness, or temporal artery tenderness. 3, 4
PMR and GCA overlap in 15–20% of cases, and GCA can develop during PMR treatment. 5, 3, 4
Visual loss from GCA is irreversible if treatment is delayed, making early recognition life-altering. 4
Action if GCA Suspected
Immediately increase prednisone to 40–60 mg daily if any GCA symptoms develop, even before confirmatory testing. 3, 4
Arrange urgent temporal artery biopsy or vascular imaging (ultrasound with halo sign, MRI, or PET-CT) within 1–2 weeks. 3
Follow-Up Schedule and Monitoring
Visit Frequency
- Every 4–8 weeks during year 1, then every 8–12 weeks during year 2, then as needed during tapering and after discontinuation. 1
At Each Visit Assess
Clinical symptoms: shoulder/hip pain, morning stiffness duration, functional status. 1
Laboratory markers: ESR and/or CRP (though these may remain suppressed on glucocorticoids). 1, 2, 6
Glucocorticoid adverse effects: blood pressure, weight, glucose (fasting or HbA1c), mood changes, sleep disturbance, skin changes, infections. 1, 2
GCA screening questions at every visit. 3
Baseline Comorbidity Assessment
- Before starting glucocorticoids, document: blood pressure, fasting glucose or HbA1c, lipid panel, creatinine, liver function tests, complete blood count, and screen for pre-existing cardiovascular disease, peptic ulcer disease, glaucoma/cataracts, and chronic infections. 1, 2
Additional Management Considerations
Methotrexate as Steroid-Sparing Agent
Consider adding methotrexate 7.5–10 mg weekly if she experiences relapse, requires prolonged therapy beyond 2 years, or develops significant glucocorticoid-related adverse effects. 1, 3
Methotrexate modestly reduces cumulative glucocorticoid exposure but is not routinely used as first-line therapy. 1, 3
Patient Education
Provide written information about PMR natural history (typically 1–2 years of treatment, 50% relapse rate during tapering), glucocorticoid side effects, and GCA warning symptoms. 1, 5, 3
Advise against abrupt glucocorticoid cessation due to adrenal suppression risk after prolonged use. 1
Specialist Referral Indications
- Refer to rheumatology if: atypical features develop (peripheral arthritis, systemic symptoms beyond PMR), inadequate response to appropriate glucocorticoid doses, frequent relapses requiring prolonged therapy, or significant glucocorticoid toxicity necessitating steroid-sparing agents. 1, 2
Common Pitfalls to Avoid
Do not use initial doses below 12.5 mg daily, as inadequate dosing leads to persistent symptoms and diagnostic confusion. 1
Do not taper too rapidly (faster than 1 mg every 4 weeks below 10 mg daily), as this is the primary cause of relapse. 1
Do not rely solely on inflammatory markers during treatment, as glucocorticoids suppress ESR/CRP; clinical symptoms guide management. 6
Do not dismiss new headache or visual symptoms as unrelated; always assume GCA until proven otherwise. 3, 4
Do not forget osteoporosis prophylaxis, as fracture risk increases within 3–6 months of starting glucocorticoids. 1, 2