Rates of glucocorticoid taper in the management of polymyalgia rheumatica: the science behind the "art".

Polymyalgia rheumatica (PMR) is a common and debilitating disease for which glucocorticoids remain the therapeutic mainstay. Guideline recommendations on tapering regimens have been largely based on expert consensus. This exploratory narrative review provides a discussion on the available evidence for the rates of steroid tapering in PMR, as well as relevant pharmacology of corticosteroids. Key studies related to rates of steroid tapering are reviewed. Results favor a slow tapering regimen from a low initial steroid dose (between 10 and 20 mg) to minimize risk of relapse. This should be balanced with the risk of steroid-induced adverse events. Individualization and close monitoring have also been identified as important factors during the steroid-tapering process. There is promising data on the role of steroid-sparing agents, including methotrexate, tocilizumab, and more recently sarilumab. There is individual variability of prednisone pharmacokinetics, and the tapering of prednisone remains an "art" that would benefit from further understanding of the variables involved. Overall, glucocorticoids remain the mainstay therapy for PMR, and there continues to be a lack of robust evidence to guide steroid taper. More research is needed to optimize steroid tapering and regimens, along with the expanding role of steroid-sparing agents such as tocilizumab and sarilumab. Key Points • Polymyalgia rheumatica is a common and debilitating disease for which glucocorticoids remain the mainstay of therapy, and there is a paucity of evidence to guide steroid taper. • Limited available research favors a slow tapering regimen from a low initial steroid dose to minimize risk of relapse and steroid exposure. • The process of steroid taper should be individualized and closely monitored, with growing evidence supporting the addition of steroid-sparing agents. • More research is needed to optimize steroid tapering and regimens, along with the expanding role of steroid-sparing agents such as methotrexate, tocilizumab, and sarilumab.