Corticosteroid therapy for the management of polymyalgia rheumatica
The approach to managing polymyalgia rheumatica, including the role of a long course of corticosteroids, is described in Management for polymyalgia rheumatica.
An example corticosteroid regimen for the treatment of polymyalgia rheumatica is:
prednisolone (or prednisone) 15 mg orally, in the morning for 4 weeks; then reduce daily dose by 2.5 mg every 4 weeks to 10 mg daily; then reduce daily dose by 1 mg every 4 to 8 weeks, according to response and tolerability, to stop. prednis ol one prednis(ol)one prednis(ol)one
Individualise the rate of corticosteroid tapering according to the patient’s circumstances, including disease activity (as indicated by symptoms and inflammatory markers) and corticosteroid adverse effects. Do not reduce the dose if the patient has signs of active disease, such as recurrence of symptoms or persistently elevated inflammatory markers.
Reconsider the diagnosis if corticosteroid therapy fails to achieve prompt symptomatic relief and a decrease in inflammatory markers.
Erythrocyte sedimentation rate (ESR) and serum C-reacrtive protein (CRP) concentration may help identify deterioration in a patient’s condition, but they are not specific measures of disease activity and should always be considered in the context of the patient’s symptoms. If a patient with well-controlled disease has elevated inflammatory markers, consider alternative pathologies (eg infection) and retest after 4 weeks. Transient rises in ESR or CRP typically do not indicate relapse. Furthermore, it is normal for these markers to increase slightly as the corticosteroid dose is reduced. Check ESR and CRP monthly for the first 3 months of therapy, then every 2 to 3 months thereafter or as clinically indicated.
If the patient has a flare of musculoskeletal or systemic symptoms during corticosteroid tapering, determine if symptoms are due to relapse; this should include measurement of inflammatory markers. Advise patients that transient symptoms, such as aching and influenza-like symptoms, are expected as the corticosteroid dose is reduced and, unless advised otherwise by their doctor, they should persist with planned dose reductions. In the absence of clinician-assessed relapse, the harms associated with prolonging corticosteroid therapy are likely to outweigh its benefits.
Approximately 50% of patients will experience at least one relapse during treatment. If assessment suggests relapse (eg symptoms for more than a few days, persistently or significantly elevated inflammatory markers that cannot be explained by another pathology), revert to the previously effective corticosteroid dose and reduce over 4 to 8 weeks to dose where the relapse occurred. Re-evaluate for the presence of giant cell arteritis, and consider referring the patient to a specialist. Specialist referral is also required if corticosteroid therapy is poorly effective, not tolerated, cannot be tapered, or is needed beyond 18 months.