Polymyalgia Rheumatica

• 15 mg daily for 3 weeks
• Then 12.5 mg for 3 weeks
• Then 10 mg for 4–6 weeks
• Then reduction by 1 mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5 mg alternate days, etc.)

Methylprednisolone

(IM depomedrone) 

• May be used in milder cases and may reduce the risk of steroid-related complications
• Initial dose is 120 mg every 3–4 weeks, reducing by 20 mg every 2–3 months
• Usually 1–2 years of treatment is needed
• The need for ongoing therapy after 2 years of treatment should prompt the consideration of an alternative diagnosis, and referral for specialist evaluation.

• Individuals with high fracture risk e.g. aged ⩾65 years or prior fragility fracture
  • Bisphosphonate eg. alendronic acid 70mg weekly
  • calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU)
  • DEXA not required
• Other individuals
  • calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU) when starting steroid therapy
  • DEXA scan recommended
  • A bone-sparing agent may be indicated if T-score is −1.5 or lower eg. alendronic acid 70mg weekly 
• Individuals requiring higher initial steroid dose
  • Bisphosphonate eg. alendronic acid 70mg weekly with calcium (1,200 - 1,500 mg daily) and vitamin D (800-1,000 IU)  

GI protection

Protein pump inhibitors

• Omeprazole 20mg od or
• Lanzoprazole 15mg od

• May be useful early in the course of treatment or later, if there is a relapse or corticosteroids are ineffective
• Methotrexate used at oral doses of 7.5–10 mg/week in clinical trials
• Methotrexate currently recommended by both international and local guidelines as the first-line steroid-sparing drug to consider in polymyalgia rheumatica
• Evidence to support this advice is of poor quality
• Leflunomide might have promise and it is currently the subject of a trial in Europe, but there may be problems with individualising the dosing.
• The use of either leflunomide or methotrexate in polymyalgia rheumatica is off label so specialist oversight is recommended.