Treatment for 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]:

1. daily prednisolone 15mg for 3 weeks
2. then 12.5mg for 3 weeks
3. then 10mg rot 4–6 weeks
4. 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.