There’s no one-size-fits-all tapering schedule that works for everyone with PMR. The process, which usually takes about two years, depends on the patient, how well symptoms are controlled, and how their body responds to dosage changes, according to Aixa Toledo-Garcia, MD, rheumatologist and chief medical officer at The Center for Rheumatology, with locations across New York.
Most people with PMR begin on a dose of prednisone in the range of about 10 to 20 mg daily, although in some cases doses can start at as high as 25 mg.
“Patients typically respond dramatically to treatment, often within one week of initiating prednisone at an average dose of 20 mg daily,” Dr. Toledo-Garcia says.
“We tend to find the lowest dose that makes patients feel back to normal. We keep them on that for two to four weeks, and then we start tapering,” Zashin says.
From there, there are different ways to approach it, including:
The Linear Taper A common approach is to reduce the dose in small, steady steps over time, especially in the early phase of treatment.
Your rheumatologist will structure reductions by about 2.5 mg every two to four weeks until you reach 10 mg daily, says Toledo-Garcia. “Beyond this point, tapering is slower, generally by 1 mg every one to two months, while closely monitoring symptoms and inflammatory markers,” she says.
It isn’t always a strict linear taper. If your PMR symptoms resurface — like the hallmark morning stiffness — or you encounter withdrawal symptoms, your doctor may temporarily increase the dose before attempting a slower reduction, Birnbaum says.
“There’s no magic formula. Everybody’s a little different,” he says. “I might overshoot and then have to go back up and come down more slowly.”
The goal isn’t necessarily zero symptoms at all times. Patients and their rheumatology team try to find the lowest dose that keeps symptoms manageable and daily life unaffected, Birnbaum says.
The Alternating Day Method Some clinicians may use alternating doses, taking a slightly higher dose one day and a lower dose the next, to help ease transitions between dose levels.
If a patient has symptom recurrence tapering from 15 mg to 12.5 mg, for example, their doctor may alternate between the two doses every other day, Zashin says. “We might say, ‘Let’s do 15 mg one day and 12.5 the next and alternate for a week or two to give things a little more time,” he explains.
Introducing Other Medications
In some cases, especially if tapering is difficult or side effects are a concern, doctors may introduce additional medications to help manage inflammation while reducing patients’ reliance on steroids.
Methotrexate may be used on occasion. “Early use of methotrexate at 7.5 to 10 mg weekly can be beneficial, particularly in patients at higher risk for long-term steroid side effects like those with diabetes or osteoporosis,” says Toledo-Garcia.
In other cases, it may be a matter of adjusting the type of steroid itself. “Some people surprisingly won’t respond to prednisone but might respond to methylprednisolone instead,” Zashin says.
Talk to your rheumatologist if tapering isn’t going smoothly. Treatment can be adjusted, not just increased or decreased, to better support the process, Zashin says.
A newer, biologic medication, approved by the U.S. Food and Drug Administration (FDA) to treat PMR in people who have an inadequate response to steroids or can’t tolerate steroid taper, is Kevzara (sarilumab). Usually reserved for severe PMR, it inhibits IL-6, a cytokine that causes inflammation; but it can have side effects, and people with PMR should carefully review the risks and benefits with their rheumatologist. A randomized controlled trial found that the use of 200 mg of sarilumab once every two weeks with a 14-week glucocorticoid taper led to clinically important improvements in health-related quality of life and patient-reported outcomes versus a placebo with a 52-week glucocorticoid taper.
Read the full article here
