Polymyalgia Rheumatica Treatment Guidelines

Initial Treatment and Dosing

The European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) recommend oral prednisone (or equivalent) at 12.5-25 mg/day as the initial treatment for polymyalgia rheumatica (PMR) 1, 2
The American College of Rheumatology recommends starting with oral prednisone 12.5-25 mg/day as a single morning dose, with higher doses (20-25 mg/day) used in patients with high relapse risk and lower doses (12.5-15 mg/day) used in patients with comorbidities that increase steroid toxicity risk 1, 2
Strongly avoid doses >30 mg/day, as these indicate a need to reconsider the diagnosis 2

After achieving clinical improvement at 2-4 weeks, taper gradually to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation 1, 2
Taper more slowly (<1 mg/month) when below 10 mg/day to reduce relapse rates 1, 2

Intramuscular methylprednisolone can be considered as an alternative to oral prednisone, particularly in patients with difficult-to-control hypertension, diabetes, osteoporosis, or glaucoma, with an initial dose of 120 mg IM every 3 weeks until week 9 2

Consider adding methotrexate 10 mg/week or higher in patients at high risk for steroid-related side effects, relapse risk, or anticipated prolonged therapy 1

Follow patients every 4-8 weeks during the first year, monitoring inflammatory markers, clinical symptoms, and systematically evaluating for glucocorticoid-related adverse effects, and assess bone mineral density and provide osteoporosis prophylaxis 1