From the Guidelines
To prevent flares of polymyalgia rheumatica (PMR), maintain consistent corticosteroid therapy as prescribed, typically starting with prednisone 12.5-25 mg daily, with gradual tapering once symptoms are controlled, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The key to managing PMR is to find the minimum effective dose of corticosteroids to control symptoms while minimizing the risk of side effects.
- Regular monitoring with a rheumatologist is essential to adjust medication dosages and check for complications.
- The panel strongly recommends individualising dose tapering schedules, predicated to regular monitoring of patient disease activity, laboratory markers and adverse events 1.
- The following principles of GC dose tapering are suggested:
- Initial tapering: Taper dose to an oral dose of 10 mg/day prednisone equivalent within 4–8 weeks.
- Relapse therapy: Increase oral prednisone to the pre-relapse dose and decrease it gradually (within 4–8 weeks) to the dose at which the relapse occurred.
- Tapering once remission is achieved (following initial and relapse therapies): Taper daily oral prednisone by 1 mg every 4 weeks (or by 1.25 mg decrements using schedules such as 10/7.5 mg alternate days, etc) until discontinuation given that remission is maintained 1.
- In addition to corticosteroid therapy, lifestyle modifications such as regular physical activity, adequate rest, stress management, and a balanced diet can help manage PMR symptoms and prevent flares.
- Steroid-sparing agents like methotrexate may be considered in cases of frequent flares or difficulty tapering steroids, as they have been shown to be effective in reducing the risk of relapse and improving outcomes in PMR patients 1.
- Calcium and vitamin D supplements should be taken to counteract steroid-induced bone loss, with a recommended dose of 1000-1200mg daily of calcium and 800-1000 IU daily of vitamin D.
- Regular follow-up visits with a rheumatologist are crucial to monitor disease activity, adjust treatment plans, and prevent complications.
- The goal of treatment is to achieve remission and taper off corticosteroids, while minimizing the risk of side effects and improving quality of life.
- By following these recommendations and working closely with a rheumatologist, patients with PMR can effectively manage their symptoms, prevent flares, and improve their overall quality of life.
From the Research
Prevention of Flare-ups in Polymyalgia Rheumatica (PMR)
To prevent flare-ups in PMR, several treatment strategies can be employed:
- Glucocorticoids: The mainstay of PMR treatment, with prednisone being the most commonly used glucocorticoid 2, 3, 4.
- Disease-modifying antirheumatic drugs (DMARDs): Methotrexate is the most commonly used DMARD in PMR, which has been shown to have a modest effect in preventing relapses 2, 3, 5.
- Tapering of prednisone: Slow tapering of prednisone (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 4.
- Combination therapy: The use of methotrexate in combination with prednisone has been shown to be effective in reducing the cumulative prednisone dose and the number of flare-ups 3, 5, 6.
Key Findings
Some key findings from the studies include:
- Methotrexate has been shown to be effective in reducing the cumulative prednisone dose and the number of flare-ups in PMR patients 3, 5, 6.
- The use of methotrexate in combination with prednisone has been shown to be effective in reducing the cumulative prednisone dose and the number of flare-ups 3, 5, 6.
- Slow tapering of prednisone (<1 mg/mo) is associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens 4.
Treatment Considerations
When considering treatment for PMR, the following should be taken into account: