Glucocorticoid Therapy

Introduction to Glucocorticoid Therapy

Glucocorticoid therapy is a common treatment for various medical conditions, with the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) providing recommendations for its management 1

The initial dose of oral prednisone equivalent should be between 12.5-25 mg/day, with single daily doses preferred over divided doses, as recommended by EULAR 1
Intramuscular methylprednisolone may be considered in specific cases where lower cumulative glucocorticoid dose is desirable, such as patients with difficult-to-control hypertension, diabetes, osteoporosis, or glaucoma, although evidence for reduced side effects with intramuscular administration is limited 1
Doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly discouraged due to increased risk of adverse effects without additional benefit, as suggested by 1
Taper to 10 mg/day within 4-8 weeks of starting treatment, and once remission is achieved, taper prednisone by 1 mg every 4 weeks (or by using alternate day schedules such as 10/7.5 mg), as recommended by 1
Tapering of prednisone should occur over at least 1-2 years, sometimes indefinitely for responders, as recommended by the American Thoracic Society (ATS) and the Endocrine Society (ES) 2, 1

Methotrexate can be considered as a steroid-sparing agent to reduce glucocorticoid dose, especially in patients with significant hair loss, as suggested by the Annals of the Rheumatic Diseases and EULAR 3, 1
Methotrexate has demonstrated effectiveness as a steroid-sparing agent in PMR, according to EULAR 3
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) as primary treatment is not recommended, except for short-term use for pain related to other conditions, and the use of anti-TNFα agents is strongly advised against in patients with PMR 1
TNFα blocking agents are strongly discouraged for PMR treatment, and certain herbal preparations are also strongly discouraged 1

Methotrexate can be continued for long-term use based on its acceptable safety profile, as stated by EULAR 3
Folic acid supplementation of at least 5 mg per week is recommended to reduce toxicity when using methotrexate, as suggested by EULAR 3
Before starting methotrexate, a clinical assessment of risk factors for methotrexate toxicity, including alcohol intake, should be performed, as recommended by EULAR 3
Laboratory tests, including liver function tests (e.g., AST, ALT), albumin, complete blood count (CBC), and creatinine, should be conducted before starting methotrexate, as stated by EULAR 3
Monitoring during treatment should include liver function tests (e.g., ALT with or without AST), creatinine, and CBC every 1-1.5 months until a stable dose is reached, then every 1-3 months thereafter, according to EULAR 3
Methotrexate is contraindicated in pregnancy planning, pregnancy, and breastfeeding, as stated by EULAR 3

Specialist referral should be considered for patients with atypical presentation, high risk of therapy-related side effects, PMR refractory to glucocorticoid therapy, or relapses or need for prolonged therapy, as recommended by 1
Patients should have an individualized PMR management plan, and education should focus on disease impact, treatment effects, and comorbidities, with individualized exercise programs recommended to maintain muscle mass and function, according to 1
Patient education about the disease and its treatment is crucial, with treatment based on shared decision-making between the patient and physician, and an individualized management plan considering patient preferences and comorbidities, as recommended by EULAR 1
Clinicians should provide stress dose education for patients on long-term therapy, and monitor for signs of adrenal insufficiency, disease relapse, and glucocorticoid withdrawal syndrome, as recommended by various medical guidelines 1