Standard initial treatment

Oral prednisone: 15 mg per day for three weeks, then 12.5 mg per day for three weeks, then 10 mg per day for four to six weeks, then decrease by 1 mg every four to eight weeks

Expect one to two years of treatment

Alternate treatment

Intramuscular methylprednisolone (Depo-Medrol): depot formulation, 120 mg every three to four weeks; decrease by 20 mg every two to three months

note: For both polymyalgia rheumatica and giant cell arteritis, treatment must be tailored to patient's symptoms and inflammatory markers followed; in giant cell arteritis, persistence of ESR/CRP elevation may indicate underlying large vessel disease or other diagnosis

Bone protection

Patients at high risk of fracture (≥ 65 years or prior fracture): bisphosphonate, calcium, and vitamin D

Polymyalgia rheumatica, low-dose corticosteroid without high fracture risk: calcium and vitamin D, DEXA scan at onset of treatment, bisphosphonate if T-score is –1.5 or lower

Follow-up visits

At one to three weeks (corticosteroids started after laboratory tests, assessment one week after starting corticosteroids); six weeks; and three, six, nine, and 12 months, with extra visits as needed

Monitor for relapse, adverse events, or atypical symptoms

Relapse symptoms: proximal pain, fatigue, morning stiffness

note: Older adults may have degenerative disorders that cause persistent pain

Development of giant cell arteritis: headaches, jaw or tongue claudication, visual disturbances

Adverse events related to corticosteroid therapy

Atypical symptoms that point to a different diagnosis

Follow-up laboratory tests (each visit)

Complete blood count, ESR/CRP, electrolyte level, blood urea nitrogen/creatinine ratio, glucose level

Management of relapse

Signs or symptoms of giant cell arteritis: follow guidelines for corticosteroid dosing (Table 5)

Polymyalgia rheumatica symptoms during taper: increase to previous dose or give a single intramuscular injection

Further relapses or inability to taper: refer to rheumatologist for consideration of disease-modifying antirheumatic drug therapy