Polymyalgia rheumatica (PMR) is very responsive to medication—most people feel markedly better within days of starting the right treatment. The backbone is glucocorticoids (steroids), often followed by steroid-sparing medicines to keep symptoms controlled while minimizing steroid side effects.
Below is the big picture; we’ll dive deep into each option in separate articles.
First-line: Glucocorticoids (Prednisone/Prednisolone)
- Why they’re used: They rapidly calm the inflammation that drives PMR pain and stiffness.
- Typical starting dose: About 12.5–25 mg/day of prednisone (or equivalent). The shared EULAR/ACR guideline recommends tapering down to 10 mg/day within 4–8 weeks, then slowing the taper after that. Relapses are handled by bumping the dose back up to the last effective level and retrying a slower taper.
- How long overall? Many patients need treatment for 1–2 years (sometimes longer), with an individualized taper based on symptoms and lab markers. Once around 10 mg/day, many clinicians slow the taper to ~1 mg every 1–2 months to reduce relapses.
- Alternatives to daily pills: Some centers use long-acting intramuscular glucocorticoid regimens as an alternative strategy in selected patients. (We’ll cover when this makes sense.)
Reducing steroid side effects (started at the same time as treatment)
- Bone protection: Calcium/vitamin D, fracture-risk assessment, and often a bisphosphonate if risk is elevated.
- Metabolic/GI: Monitor blood sugar and blood pressure; consider a PPI if you’re at GI-bleed risk.
- Vaccines: Keep routine immunizations up to date before/while on immunosuppression.
(These risk-reduction steps are emphasized across PMR guidance.)
Steroid-Sparing Medicines (add-on or sometimes early)
Used to lower the total steroid dose, prevent relapses, or help if side effects are a concern.
Methotrexate (MTX)
- What it does: A conventional DMARD that can reduce relapses and cumulative steroid exposure in PMR for some patients (benefit is modest but meaningful for those at high steroid-risk).
- Typical dosing: 10–15 mg once weekly to start (often titrated), with folic acid for side-effect prevention and periodic lab monitoring.
- When considered: Early in people likely to relapse or who are vulnerable to steroid toxicity (e.g., diabetes, osteoporosis, glaucoma). This approach aligns with international guidance.
Other conventional agents like leflunomide or azathioprine are sometimes tried when MTX isn’t suitable; the evidence base is smaller — we’ll cover pros/cons separately.)
Biologics Targeting Interleukin-6 (IL-6)
Sarilumab
- Status: FDA-approved (Feb 28, 2023) for adults with PMR who cannot taper steroids or who had an inadequate response. It’s the first approved biologic for PMR.
- How it’s used: Subcutaneous injections on a fixed schedule, with lab monitoring and infection-risk counseling per the product label. (We’ll detail dosing, labs, and safety in its dedicated article.)
Tocilizumab
- Status: Not FDA-approved specifically for PMR, but studied off-label. The PMR-SPARE randomized trial in new-onset PMR found tocilizumab improved glucocorticoid-free remission vs. placebo alongside a structured taper. Additional syntheses continue to appear. Your clinician may consider it in selected, difficult cases.
NSAIDs and Pain Relievers
- Role: Limited. NSAIDs and simple analgesics may ease residual aches but do not control PMR inflammation and aren’t adequate as stand-alone therapy. Use cautiously in older adults because of GI, kidney, and cardiovascular risks.
What to Expect Over the Course of Treatment
- Fast relief, slow taper: Most people feel better within days of starting steroids; then the work is slowly tapering without triggering flares.
- Relapses happen: They’re common. The usual step is to return to the last effective steroid dose, then taper more gradually; adding a steroid-sparing agent may be helpful.
- Always watch for GCA symptoms: New headache, jaw pain when chewing, scalp tenderness, or vision changes require urgent medical assessment and higher steroid dosing if giant cell arteritis is suspected. (We’ll cover this intersection in detail elsewhere.)
Where Guidelines Stand Today
- The 2015 EULAR/ACR PMR recommendations remain the core, especially for steroid starting doses and taper strategy.
- The British Society for Rheumatology (BSR) is actively updating its PMR guideline (expected Autumn 2025); we’ll incorporate changes as they publish.
Bottom Line
- Start with steroids, taper thoughtfully, and prevent side effects from day one. Then, add a steroid-sparing medicine (most often methotrexate) if relapse risk or steroid toxicity is a concern. Consider IL-6 inhibitors in steroid-refractory or steroid-intolerant PMR — sarilumab is now FDA-approved for this scenario.
- Your exact plan should be individualized based on symptoms, labs, other medical conditions, and your response over time. Your clinician will know what’s the best course of action for you.
Medical disclaimer: This overview is educational and does not replace care from your clinician. If you develop any symptoms suggestive of giant cell arteritis, seek urgent evaluation.
