A 75-year-old woman is evaluated for a 2-week history of gradually increasing pain in both shoulders and hips; the pain radiates down both arms to the elbows and down both hamstrings to the knees. She reports no headache, jaw claudication, or vision changes. She was diagnosed with polymyalgia rheumatica 3 months ago. She started prednisone, 15 mg/d, with immediate and complete relief of symptoms; prednisone was weaned from 15 to 10 mg/d 2 months ago, then to 8 mg/d (current dose) 1 month ago. She remained asymptomatic until 2 weeks ago. She says that her current symptoms are just as bad as when she was first diagnosed.
On physical examination, vital signs are normal; blood pressure is identical in both arms. There is no temporal tenderness or induration. Painful range of motion of both shoulders and hips is noted.
Which of the following is the most appropriate management?
A. Prednisone, 10 mg/d
B. Prednisone, 30 mg/d
C. Prednisone, 60 mg/d
D. Prednisone, 20 mg/d, and methotrexate
MKSAP Answer and Critique
The correct answer is A. Prednisone, 10 mg/d. This content is available to MKSAP 18 subscribers as Question 31 in the Rheumatology section. More information about MKSAP is available online.
Prednisone, 10 mg/d, is the most appropriate treatment for this patient with a relapse of polymyalgia rheumatica (PMR) after her prednisone dose was weaned to 8 mg/d. Patients with PMR experience symmetric pain and stiffness in the shoulder, neck, and hip regions, typically without synovitis. PMR is a clinical diagnosis based on the characteristic symptoms in a patient older than 50 years and is supported by an elevated erythrocyte sedimentation rate and/or C-reactive protein. Recent guidelines for the management of PMR (developed by a collaborative effort of the American College of Rheumatology and the European League Against Rheumatism) recommend increasing the prednisone to the last pre-relapse dose at which the patient was doing well, followed by a gradual reduction within 4 to 8 weeks back to the relapse dose. This patient was asymptomatic on 10 mg/d, prior to reducing to her current relapse dose; therefore, an increase to 10 mg/d is appropriate. After the flare-up subsides, a slow taper of 1 mg every 4 weeks may be better tolerated then larger increments over 2- to 4-week periods.
Prednisone, 30 mg/d, would also help treat the flare-up, but this higher dose is probably unnecessary, and a lower dose should be attempted first.
Prednisone, 60 mg/d, is not a typical dose used for PMR, and in the absence of concomitant giant cell arteritis is not needed to treat a PMR flare-up.
Methotrexate can be added as a glucocorticoid-sparing agent for patients who cannot be successfully weaned off prednisone or who are experiencing significant glucocorticoid toxicity; this patient has only had one flare-up and may do well after a modest increase followed by a more gradual taper of prednisone, making the addition of methotrexate premature at this time.
- A relapse of polymyalgia rheumatica should be treated with an increase in prednisone to the last pre-relapse dose at which the patient was doing well, followed by a gradual reduction within 4 to 8 weeks back to the relapse dose.