Polymyalgia rheumatica Investigation and management Clinical evaluation Assess for and exclude relevant mimicking conditions (non-inflammatory, inflammatory, drug-induced, endocrine, infective, and neoplastic) as part of the initial evaluation of patients with PMR. Laboratory tests Obtain the following tests as part of the initial evaluation of patients with PMR, before the initiation of treatment: CBC CRP and/or ESR glucose creatinine LFTs RF ACPA bone profile urinalysis. Corticosteroids, dosing and duration Consider using the minimum effective corticosteroid dose within a range of 12.5-25 mg prednisone (or equivalent) daily as the initial treatment for PMR. C Consider using a higher initial prednisone dose within this range in patients with a high risk of relapse and low risk of adverse events. C Consider using a lower initial dose within this range in patients with risk factors for corticosteroid side effects (such as diabetes, osteoporosis, and glaucoma). C Avoid the use of initial prednisone doses 7.5 mg/day and the use of initial doses 30 mg/day. D Consider IM methylprednisolone as an alternative to oral corticosteroids, at the discretion of the treating physician. C Use the minimally effective duration of corticosteroid therapy. A Methotrexate EULAR Q Is the patient at high risk for relapse or show clinical evidence of relapse? Q Is the patient at high risk of glucocorticoid-related adverse events? Yes to any Consider introducing methotrexate early (7.5-10 mg/week), in addition to corticosteroids, in patients at high risk for relapse and in patients in whom corticosteroid-related adverse events are more likely to occur. C Consider initiating methotrexate in patients: with clinical relapse without significant response to corticosteroids with corticosteroid-related adverse effects. C No to all Biological agents Do not use TNF inhibitors for the treatment of patients with PMR. D Follow-up Monitor the following elements during follow-up of patients with PMR: risk factors and evidence for steroid-related side effects comorbidities other relevant medications evidence and risk factors for relapse/prolonged therapy. Schedule follow-up: Situation Guidance First year Every 4-8 weeks Second year Every 8-12 weeks Relapse or as prednisone is tapered and discontinued As indicated. Indications for referral Consider referring patients with PMR for specialist evaluation, particularly in the following situations: patients with atypical presentation (such as peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age < 60 years) high risk or occurence of therapy-related side effects PMR refractory to corticosteroid therapy occurence of relapses or need for prolonged therapy. 