In a woman over 50 presenting with bilateral shoulder and hip girdle pain, morning stiffness lasting more than 30 minutes, and elevated erythrocyte sedimentation rate or C‑reactive protein, how is polymyalgia rheumatica diagnosed and what is the recommended first‑line management, including glucocorticoid dosing, tapering schedule, adjunctive therapies, and screening for giant cell arteritis?

Polymyalgia Rheumatica: Diagnosis and Management

Diagnosis

Polymyalgia rheumatica is diagnosed clinically in patients over 50 years with bilateral shoulder and hip girdle pain, morning stiffness exceeding 30 minutes, elevated ESR or CRP, and exclusion of mimicking conditions through targeted laboratory testing. 1

Clinical Criteria

• Age ≥50 years with bilateral shoulder pain, morning stiffness >30 minutes, and functional impairment form the diagnostic triad 1
• Symptoms typically develop acutely or over days to weeks 2
• Constitutional symptoms (fatigue, fever, weight loss) may occur due to systemic IL-6 signaling 2

Essential Laboratory Workup

• Core inflammatory markers: ESR and/or CRP must be elevated; ESR >40 mm/1st hour predicts higher relapse rates 1, 3
• Autoantibody panel: Rheumatoid factor and anti-CCP antibodies to exclude rheumatoid arthritis 1
• Complete blood count to assess for alternative causes of inflammation or anemia 1
• Metabolic panel: Glucose, creatinine, liver function tests establish baseline before glucocorticoid therapy 1
• Bone profile: Calcium and alkaline phosphatase assess pre-treatment bone health 1
• Creatine kinase: Must be normal to differentiate from inflammatory myositis 1
• Additional testing when indicated: Protein electrophoresis (paraproteinemia), TSH (thyroid disorders), ANA/ANCA (other autoimmune diseases), tuberculosis screening before immunosuppression 1

Diagnostic Pitfalls

• No single test is pathognomonic; diagnosis remains clinical with supportive laboratory evidence 1
• Refer to rheumatology for atypical presentations: age <60 years, peripheral inflammatory arthritis, systemic symptoms, or normal inflammatory markers 1

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First-Line Glucocorticoid Management

Start prednisone 12.5–25 mg daily, with most patients requiring 15–20 mg; taper to 10 mg within 4–8 weeks if symptoms resolve, then reduce by 1 mg every 4 weeks until discontinuation. 4, 5

Initial Dosing Strategy

• Standard dose: 15–20 mg daily for most patients 1
• Higher dose (20–25 mg): For patients with high relapse risk (female sex, ESR >40, peripheral arthritis) and low adverse event risk 5, 3
• Lower dose (12.5–15 mg): For patients with diabetes, osteoporosis, glaucoma, or other glucocorticoid-related risk factors 5
• Never exceed 30 mg/day (reserved for giant cell arteritis) or use <7.5 mg/day (insufficient anti-inflammatory effect) 5, 1
• Dramatic clinical improvement occurs within 7 days in most patients; lack of response by 2 weeks warrants dose escalation to 25 mg or diagnostic reconsideration 5, 1

Tapering Protocol

Phase 1: Initial Taper (Weeks 0–8)

• Reduce to 10 mg daily over 4–8 weeks once clinical remission achieved (resolution of pain/stiffness, normalization of inflammatory markers) 4, 5

Phase 2: Maintenance Taper (From 10 mg onward)

• Decrease by 1 mg every 4 weeks until discontinuation 4
• Alternative: Use alternating schedules (e.g., 10/7.5 mg on alternate days) to achieve 1.25 mg decrements 1
• Total treatment duration typically 1–2 years; ~50% of patients experience relapse during tapering 1

Detailed Taper Schedule from 10 mg:

Timeframe	Daily Dose	Duration
Weeks 1-4	10 mg	4 weeks
Weeks 5-8	9 mg	4 weeks
Weeks 9-12	8 mg	4 weeks
Weeks 13-16	7 mg	4 weeks
Weeks 17-20	6 mg	4 weeks
Weeks 21-24	5 mg	4 weeks
Weeks 25-28	4 mg	4 weeks
Weeks 29-32	3 mg	4 weeks
Weeks 33-36	2 mg	4 weeks
Weeks 37-40	1 mg	4 weeks
Week 41+	Discontinue	-

4

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Relapse Management

If symptoms recur during tapering, immediately increase prednisone to the pre-relapse dose, maintain for 4–8 weeks, then resume tapering at a slower rate. 4, 5

• After 4–8 weeks of disease control, gradually decrease over 4–8 weeks back to the dose where relapse occurred 4
• Continue tapering at ≤1 mg per month thereafter 5
• High baseline ESR (>40 mm/h) and female sex predict greater relapse likelihood, requiring especially vigilant monitoring 3, 1

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Adjunctive Therapies

Methotrexate as Steroid-Sparing Agent

Add methotrexate 7.5–10 mg weekly with folic acid supplementation for patients experiencing multiple relapses, significant glucocorticoid adverse effects, or risk factors for steroid toxicity. 4, 3

• Methotrexate modestly reduces cumulative glucocorticoid exposure but is not first-line therapy 1
• Female patients have higher risk of glucocorticoid adverse events and should be considered earlier for methotrexate 4, 1

Intramuscular Methylprednisolone

• Alternative to oral prednisone in patients with poorly controlled hypertension, diabetes, osteoporosis, or glaucoma 4
• Evidence for reduced side effects is limited; one RCT showed only lower weight gain 4

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Osteoporosis Prophylaxis

Initiate calcium 1,200–1,500 mg daily, vitamin D 800–1,000 IU daily, and bisphosphonate therapy (alendronate 70 mg weekly or risedronate 35 mg weekly) immediately upon glucocorticoid initiation in postmenopausal patients. 1

• Fracture risk rises within 3–6 months of glucocorticoid initiation 1
• Female patients have intrinsically higher risk of glucocorticoid-induced osteoporosis, making prophylaxis mandatory 1
• Weight-bearing exercise 30–60 minutes daily counteracts prednisone-associated bone loss 5

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Monitoring Schedule

Follow patients every 4–8 weeks during the first year, every 8–12 weeks in the second year, and as needed thereafter. 4, 1

At Each Visit Assess:

• Clinical symptoms: Shoulder/hip pain, morning stiffness duration, functional status 1
• Laboratory markers: ESR and/or CRP (recognizing glucocorticoids may suppress them) 1
• Glucocorticoid adverse effects: Blood pressure, weight, glucose control, mood, sleep, skin changes, infections 1
• Signs of adrenal insufficiency when tapering below 5 mg daily 4

Baseline Comorbidity Assessment (Before Starting Therapy):

• Hypertension, diabetes/glucose intolerance, cardiovascular disease, dyslipidemia 5, 1
• Osteoporosis risk, peptic ulcer disease, glaucoma/cataracts 5, 1
• Chronic or recurrent infections, tuberculosis risk 1

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Screening for Giant Cell Arteritis

Educate all PMR patients on warning signs of giant cell arteritis: new-onset headache, visual disturbances, jaw claudication, scalp tenderness, or temporal artery abnormalities. 6

• PMR and GCA share pathogenetic and epidemiological features; GCA may complicate PMR and requires immediate high-dose glucocorticoids (40–60 mg prednisone daily) to prevent blindness 6, 7
• Provide direct access to healthcare providers for reporting new symptoms 5

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Critical Pitfalls to Avoid

• Do not start doses <12.5 mg/day: Sub-therapeutic dosing leads to persistent symptoms and diagnostic uncertainty 5, 1
• Do not taper faster than 1 mg every 4 weeks below 10 mg/day: Rapid tapering is the principal cause of relapse 4, 1
• Do not omit osteoporosis prophylaxis: Fracture risk rises rapidly after glucocorticoid initiation 1
• Do not abruptly discontinue glucocorticoids: Risk of adrenal suppression after prolonged use 1
• Do not neglect cardiovascular risk assessment: Glucocorticoids exacerbate multiple metabolic disturbances beyond bone health 5

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Patient Education

• Provide written information on the typical 1–2-year treatment course and ~50% relapse rate during tapering 1
• Counsel on glucocorticoid side effects and self-monitoring for disease flares 5
• Advise low-glycemic-index diet to minimize steroid-induced hyperglycemia 5
• Ensure direct access to healthcare providers for reporting flares or adverse events 5