Polymyalgia Rheumatica Treatment Guidelines

Initial Glucocorticoid Therapy

The European League Against Rheumatism recommends starting with prednisone 12.5-25 mg daily as first-line therapy for patients with polymyalgia rheumatica 1
Higher initial doses within this range (closer to 25 mg) may be appropriate for patients with high risk of relapse and low risk of adverse events, according to the European League Against Rheumatism 1
Lower initial doses within this range (closer to 12.5 mg) should be used for patients with relevant comorbidities (diabetes, osteoporosis, glaucoma), as recommended by the European League Against Rheumatism 1
Initial doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly recommended against by the European League Against Rheumatism 1
Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids, according to the European League Against Rheumatism 1

The European League Against Rheumatism recommends reducing the dose to 10 mg/day prednisone equivalent within 4-8 weeks, followed by a tapering schedule 1
Once remission is achieved, the European League Against Rheumatism suggests tapering prednisone by 1 mg every 4 weeks (or using alternate-day schedules like 10/7.5 mg) until discontinuation 1, 2

For relapse, the European League Against Rheumatism recommends increasing prednisone to the pre-relapse dose and decreasing gradually (within 4-8 weeks) to the dose at which relapse occurred 1, 2
After re-establishing control, the European League Against Rheumatism suggests reducing more slowly than initially, not exceeding 1 mg per month 2
For persistent nighttime pain when tapering below 5 mg/day, the European League Against Rheumatism recommends considering splitting the daily dose rather than using a single morning dose 1, 2

Methotrexate (7.5-10 mg weekly) should be considered as an adjunctive therapy in patients at high risk for relapse or prolonged therapy, according to the European League Against Rheumatism 1
Methotrexate should also be considered for patients with risk factors for glucocorticoid-related adverse events, as recommended by the European League Against Rheumatism 1
The European League Against Rheumatism suggests considering methotrexate for patients who have experienced a relapse without significant response to glucocorticoids 2
Methotrexate should be considered for patients experiencing glucocorticoid-related adverse events, according to the European League Against Rheumatism 1

The European League Against Rheumatism strongly recommends against the use of TNFα blocking agents (such as infliximab) for PMR treatment 1
Chinese herbal preparations Yanghe and Biqi capsules are strongly recommended against by the European League Against Rheumatism 1

Regular monitoring of disease activity, laboratory markers (ESR, CRP), and adverse events is essential for individualizing treatment, according to the European League Against Rheumatism 1, 2
The European League Against Rheumatism recommends follow-up visits every 4-8 weeks during the first year of treatment 2
Systematically evaluating for glucocorticoid-related adverse effects, particularly bone mineral density, is recommended by the European League Against Rheumatism, as prednisone can cause significant bone loss 2

The European League Against Rheumatism recommends obtaining ESR and/or CRP, glucose, creatinine, liver function tests, calcium, alkaline phosphatase, and urinalysis before initiating glucocorticoids, and considering protein electrophoresis, TSH, creatine kinase, and vitamin D 3
The American College of Rheumatology suggests assessing for glucocorticoid adverse effects (bone density, blood pressure, glucose, cataracts, infections) and documenting disease activity at each visit, every 4-8 weeks during the first year and every 8-12 weeks during the second year 3

Refer to rheumatology for atypical presentation (age <60 years, low inflammatory markers, peripheral inflammatory arthritis, systemic symptoms), refractory disease despite appropriate glucocorticoid therapy, or significant glucocorticoid-related adverse effects, as recommended by the European League Against Rheumatism 3

The American College of Rheumatology recommends that all patients on chronic glucocorticoids require calcium and vitamin D supplementation, and assessing bone mineral density and considering bisphosphonate therapy, particularly for patients with prior fractures or prolonged treatment anticipated 3