Understanding the Role of Steroid Treatment in Polymyalgia Rheumatica

If you’ve recently been diagnosed with polymyalgia rheumatica (PMR), you may have several questions about what this means for you and what typical treatment looks like.  

PMR is an inflammatory disorder that results in stiffness and pain, particularly in your shoulders and hips — and most people who develop it are over the age of 65, per the Mayo Clinic. Other symptoms might include limited range of motion, mild fever, fatigue, loss of appetite, and unintended weight loss. 

The annual incidence of PMR varies from 12 to 60 cases per 100,000 individuals, with the highest rate in those of Northern European descent and women, per a 2020 review in the Cleveland Clinic Journal of Medicine. The mainstay treatment for PMR is oral prednisone therapy. 

“Steroids are one of the few medications that work quickly to reduce inflammation dramatically,” says Aly Cohen, MD, a rheumatologist at Integrative Rheumatology Associates in Princeton, New Jersey. “They’re really a remarkable invention. When it comes to PMR, steroids are typically a very well-studied and practical first-line therapy.”  

What to Expect from Steroid Treatment in PMR

As you explore treatment options for PMR, your doctor may discuss steroid treatment with you — including the results you can expect and how soon you’ll be able to reduce dosage. “Classically, most patients with PMR feel quite debilitated when they are initially diagnosed or when they first have their symptoms,” says Anisha Dua, MD, MPH, Associate Professor of Rheumatology at Northwestern University. “A low to moderate dose of steroids is usually extremely effective in controlling symptoms or making them feel much closer to normal, with a pretty rapid onset.” 

You may experience relief in as little as one to three days. PMR is considered a very steroid-responsive disease, so if you don’t see improvement after a week, your doctor may reevaluate your diagnosis. Many patients can taper off of steroids without flares in about a year. (That said, some may need to be on steroids for longer.) During that time, your doctor will be consistently reassessing your clinical symptoms and lab tests, while trying to slowly wean you off the steroids.  

“PMR is considered a very manageable condition that can be cured with standard of care therapy after 12 to 15 months in most individuals,” says Brett Smith, DO, a rheumatologist at Tennessee Direct Rheumatology and East Tennessee Children’s Hospital. “That said, delay in diagnosis and treatment can prolong symptoms and create an increased risk of adverse effects from medication if we deviate from long-term management guidelines.” 

Common Steroid Medications for Polymyalgia Rheumatica

The go-to options for treating PMR are prednisone and prednisolone. Both are oral medications and steroids. Prednisone treats symptoms of low corticosteroid levels, which are typically made by the body for normal functioning, per the U.S. National Library of Medicine. By shifting how the immune system works, it can help reduce swelling. It’s usually taken one to four times per day, or once every other day. 

In the liver, prednisone is converted into prednisolone. The latter may be used in people who have lower liver functioning. “Prednisolone bypasses the liver, so it is often given to patients who have chronic liver disease, fatty liver, elevated liver function tests, or take other medications that go through the liver,” says Dr. Cohen. “Otherwise, prednisone and prednisolone are essentially equivalent.” 

Providers typically prescribe between 10 to 25 milligrams of steroid treatment per day. “Once we see a clinical response, the plan is to try to taper the glucocorticoids,” says Dr. Dua. “If patients respond well with no symptoms of flare whatsoever, we’re able to follow tapering strategies and get them off of steroids.” Glucocorticoids are the class of steroid hormones that prednisone and prednisolone belong to.  

Patients still taking glucocorticoids at one, two, and five years were respectively 77 percent, 51 percent, and 25 percent, per a 2021 study in Clinical Rheumatology. Forty-three percent of patients experienced at least one relapse a year after starting treatment.  

Potential Side Effects of Steroid Treatment in PMR

As with most medications, you may notice side effects when you start taking steroids.  

Oral drugs like these get absorbed through the stomach, so it’s important to eat food when you take them (gut irritation is a common side effect), says Dr. Cohen. With steroid usage, it’s also important to avoid anti-inflammatory painkillers, since combining them with steroids can increase the risk of developing a gastric bleed or gut ulceration.  

“In the short-term, patients will sometimes notice difficulty with sleep, feel more awake, and be hungrier,” says Dr. Smith. “Patient education before treatment initiation would be the single most important factor in managing these symptoms.” 

In other words, make sure your doctor reviews potential side effects with you so that you know what to expect and how to mitigate those symptoms. It’s also important to recognize the long-term effects steroids can have on your body. “One of the common side effects is high blood sugar from the use of steroids, so you can get worsening of or new onset diabetes,” says Dr. Dua. “Osteoporosis, glaucoma, and blood pressure are also things that can worsen with prednisone use.” 

Risks Associated with Prolonged Steroid Use in PMR

Bone health and eye health are two particularly common concerns when it comes to monitoring patients with long-term steroid use in PMR. Certain steroids like prednisone can reduce the body’s ability to absorb calcium and speed up how quickly bone breaks down, increasing the risk of developing osteoporosis, per Cedars-Sinai.  

“A few ways to protect bone health include engaging in resistance training two to three times per week, taking a daily vitamin D3 supplement, and discussing the need for a prophylactic bisphosphonate while on steroid therapy,” says Dr. Smith.

Bisphosphonate drugs help to slow down that process in which bone tissue breaks down and its minerals like calcium enter the bloodstream. Prophylactic means it’s used as a preventive way. Glucocorticoids like prednisone can also raise eye pressure, so this may need to be analyzed throughout the course of treatment — especially if you have a history of glaucoma. High eye pressure may increase the risk of glaucoma by damaging the optic nerve, per the National Eye Institute.  

Meanwhile, cataracts can also be a concern for those on steroid treatment. “Cataracts can develop after long-term use of steroids, so anyone who has cataracts also needs to have those evaluated, keeping in mind that they may be using steroids for six months to a year,” says Dr. Cohen.  

In addition to your specialist and primary physician, talk to your eye doctor about your steroid treatment. They may recommend you schedule frequent exams to monitor eye pressure.   

Talking to Your Doctor About Steroids for PMR

Open communication with your doctor will help you navigate potential side effects of treatment. “It would be best to ask if the side effects are preventable, what to do with each one if they occur, and when to call the office with concerns,” says Dr. Smith.  

If you experience adverse effects to steroids that can’t be resolved or you’re unable to taper off of steroids, other medications are available to help. “There is some limited data that methotrexate may be helpful, which is a once-weekly pill or injectable,” says Dr. Smith. “Another recent option is sarilumab (Kevzara), a biologic medication that is injected under the skin every two weeks. These medications can potentially lessen the steroid burden in patients and lead to positive outcomes when used correctly.”  

Log your PMR symptoms so you can discuss them with your doctor and tailor an appropriate treatment plan. Ask your doctor which other providers you should be seeing for adequate monitoring and follow-up. As you see different providers, make sure your doctors are communicating with each other or that you’re updating each of your providers on any new medication. 

“Traditionally, comorbidities — whether it’s diabetes or high blood pressure — are all affected by medications, and prednisone can raise blood pressure as well,” says Dr. Cohen. “Some people who have high blood pressure might be given more medication for blood pressure, even though it’s the prednisone that’s really causing the issue.” 

When you work closely with your doctor to develop and monitor your PMR treatment, you’ll have a higher likelihood of mitigating side effects and making long-term management more effective. 

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This article was made possible with support from Sanofi.