Treatment for PMR
Back to Hip and shoulder pain in older adults – PMR Glucocorticoids are the first-line treatment for PMR.
Dose tapering
Once symptoms are under control the glucocorticoid dose should be gradually tapered to reduce the risk of side-effects. If the patient feels their PMR is well controlled, there's no need to recheck their inflammatory markers before reducing the dose.
Some patients need a much slower taper than others and there's little evidence to help decide how to taper the dose. As some patients develop significant glucocorticoid toxicity it's usually recommended to try a quicker taper first but to slow this taper down if necessary to keep the PMR symptoms under control.
The BSR/BHPR 2009 guidelines suggest the following regimen [reproduced with permission from B Dasgupta and Oxford University Press]:
daily prednisolone 15mg for 3 weeks
then 12.5mg for 3 weeks
then 10mg rot 4–6 weeks
then reduction by 1mg every 4–8 weeks OR alternate day reductions (e.g. 10/7.5mg alternate days)
A transient (<1 week) increase in PMR-like symptoms after the dose is reduced is common and usually manageable if you pre-warn the patient. Many patients self-manage pain and stiffness with heat packs and simple analgesia.
Long-term steroid treatment
The average length of glucocorticoid treatment for PMR (based on hospital cohorts) is around two years but with wide variation. Patients on long-term steroid treatment for PMR should be:
offered access to support and information about their condition and its treatment
made aware of potentially related symptoms which they should report
given a steroid card and advised to double the dose of steroids if they become acutely unwell
offered seasonal vaccinations such as influenza and pneumococcal vaccine
offered general advice relating to keeping active, optimal posture, diet, the use of heat, minimising the risk of falls and pacing strategies
regularly monitored, assessing the risks and side-effects of glucocorticoids.
Risks of long-term steroid treatment
The following risks should be considered as appropriate for each patient:
weight gain
skin fragility
changes in physical appearance
infections
glaucoma
steroid myopathy
osteoporosis/fracture
avascular necrosis
hypertension
diabetes
psychiatric morbidity
peptic ulcers.
Steroids and bone health
Glucocorticoids increase bone resorption and reduce bone formation. The risk of bone loss is most pronounced in the first few months of use, followed by slower but steady loss of bone with continued use.
Fracture risk assessment tools such as Qfracture and FRAX can be used to estimate fracture risk, followed up with a DEXA scan if appropriate to establish actual bone density.
As a minimum you should:
consider prescribing calcium and vitamin D supplements where appropriate
advise the patient to take regular weight-bearing exercise, which may help to promote bone strength and reduce the risk of fractures.
If bone-sparing therapy is indicated then bisphosphonates can be used.
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Hip and shoulder pain in older adults – PMR
Symptoms of PMR
Examination for PMR
Investigations for PMR
Diagnosing PMR
Treatment for PMR
Reviewing PMR patients
Diagnosing and treating giant cell arteritis (GCA)
Referring patients with PMR
Summary and further reading
Case studies
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