# Polymyalgia rheumatica (PMR referral & management) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: BSR/BHPR Guideline for Polymyalgia Rheumatica for the regimen, with the dose from Egyptian National Drug Formulary - Endocrine System Drugs 2024, Prednisolone monograph (printed pages 169-170): "Oral: Usual Initial doses: 5 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses." and "Abrupt withdrawal is not recommended particularly with doses 40 mg or more or 3 weeks of treatment or more." The formulary states a general adult range rather than a polymyalgia regimen; the 15 mg start and the taper are from the BSR/BHPR guideline, which is not held in this corpus. · BSR/BHPR Guideline for Polymyalgia Rheumatica · KEVZARA (sarilumab) injection US prescribing information, boxed warning, section 1.2 Polymyalgia Rheumatica, section 2.1 General Considerations Prior to Administration and section 2.3 Recommended Dosage for Polymyalgia Rheumatica (DailyMed SetID 827bc01c-d379-4266-a18c-c7f904b76af3) · Methotrexate 2.5mg Tablets BP SmPC sections 4.3 and 4.4 (eMC product 4608) · Accrete D3 film-coated tablets SmPC sections 2 and 4.2 (eMC product 2766) - Verified date: 2026-08 ## Verified against - BSR/BHPR Guideline for Polymyalgia Rheumatica for the regimen, with the dose from Egyptian National Drug Formulary - Endocrine System Drugs 2024, Prednisolone monograph (printed pages 169-170): "Oral: Usual Initial doses: 5 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses." and "Abrupt withdrawal is not recommended particularly with doses 40 mg or more or 3 weeks of treatment or more." The formulary states a general adult range rather than a polymyalgia regimen; the 15 mg start and the taper are from the BSR/BHPR guideline, which is not held in this corpus. - BSR/BHPR Guideline for Polymyalgia Rheumatica - Polymyalgia Rheumatica - disease-level clinical article (polymyalgia-rheumatica-referral-full.txt) - Polymyalgia rheumatica (PMR referral & management) - disease-level clinical article (polymyalgia-rheumatica-referral-clinical.txt) - KEVZARA (sarilumab) injection US prescribing information, boxed warning, section 1.2 Polymyalgia Rheumatica, section 2.1 General Considerations Prior to Administration and section 2.3 Recommended Dosage for Polymyalgia Rheumatica (DailyMed SetID 827bc01c-d379-4266-a18c-c7f904b76af3) - Methotrexate 2.5mg Tablets BP SmPC sections 4.3 and 4.4 (eMC product 4608) ## Treatment metadata - Prednisolone — 5 mg — oral.solid - Referral & safety-netting (no drug therapy) - Sarilumab — 200 mg — injection - Calcium carbonate — 600 mg — oral.solid - Methotrexate — oral.solid ## Complete treatment card ```text POLYMYALGIA RHEUMATICA (PMR REFERRAL & MANAGEMENT) Sources: BSR/BHPR Guideline for Polymyalgia Rheumatica for the regimen, with the dose from Egyptian National Drug Formulary - Endocrine System Drugs 2024, Prednisolone monograph (printed pages 169-170): "Oral: Usual Initial doses: 5 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses." and "Abrupt withdrawal is not recommended particularly with doses 40 mg or more or 3 weeks of treatment or more." The formulary states a general adult range rather than a polymyalgia regimen; the 15 mg start and the taper are from the BSR/BHPR guideline, which is not held in this corpus. · BSR/BHPR Guideline for Polymyalgia Rheumatica · KEVZARA (sarilumab) injection US prescribing information, boxed warning, section 1.2 Polymyalgia Rheumatica, section 2.1 General Considerations Prior to Administration and section 2.3 Recommended Dosage for Polymyalgia Rheumatica (DailyMed SetID 827bc01c-d379-4266-a18c-c7f904b76af3) · Methotrexate 2.5mg Tablets BP SmPC sections 4.3 and 4.4 (eMC product 4608) · Accrete D3 film-coated tablets SmPC sections 2 and 4.2 (eMC product 2766) Review status: REVIEWED against BSR/BHPR Guideline for Polymyalgia Rheumatica for the regimen, with the dose from Egyptian National Drug Formulary - Endocrine System Drugs 2024, Prednisolone monograph (printed pages 169-170): "Oral: Usual Initial doses: 5 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses." and "Abrupt withdrawal is not recommended particularly with doses 40 mg or more or 3 weeks of treatment or more." The formulary states a general adult range rather than a polymyalgia regimen; the 15 mg start and the taper are from the BSR/BHPR guideline, which is not held in this corpus., BSR/BHPR Guideline for Polymyalgia Rheumatica, Polymyalgia Rheumatica - disease-level clinical article (polymyalgia-rheumatica-referral- full.txt), Polymyalgia rheumatica (PMR referral & management) - disease-level clinical article (polymyalgia-rheumatica-referral- clinical.txt), KEVZARA (sarilumab) injection US prescribing information, boxed warning, section 1.2 Polymyalgia Rheumatica, section 2.1 General Considerations Prior to Administration and section 2.3 Recommended Dosage for Polymyalgia Rheumatica (DailyMed SetID 827bc01c-d379-4266-a18c-c7f904b76af3), Methotrexate 2.5mg Tablets BP SmPC sections 4.3 and 4.4 (eMC product 4608) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Morning stiffness lasting more than 45 minutes, worse after rest, is characteristic. [joint stiffness] - Onset is rapid, typically developing over a day to two weeks. - A persistent high fever is atypical for PMR and should raise concern for giant cell arteritis. [fever] - Pitting edema of the hands or feet, when present, responds rapidly to steroid treatment. [leg swelling] SIGNS - what you find (2) - Active shoulder movement is limited by pain, but passive range of motion is often preserved on careful exam. [reduced range of movement] - Formal strength testing is usually normal despite the patient's report of weakness. TESTS (7) - An ESR above 40 mm/h is considered the significant threshold by most authors. - ANA, rheumatoid factor, and anti-CCP antibodies are negative, and CPK is normal, helping exclude myositis or seropositive arthritis. - The 2012 classification criteria require age 50 or older, bilateral shoulder aching, an abnormal CRP or ESR, and a points threshold from morning stiffness, hip involvement, and negative serology. - MRI enhancement at the proximal rectus femoris tendon origin is a highly specific and sensitive finding. - PET/CT found large-vessel vasculitis in over 60% of PMR patients whose classic symptoms persisted without cranial GCA features. - A new headache, visual or jaw symptoms, a tender or pulseless temporal artery, absent peripheral pulses, persistent markers, high fever, or refractory symptoms are red flags for GCA. - Routine temporal artery biopsy is not recommended for patients with PMR. IF NOT THIS - what else fits (2) - About 20% of PMR patients are later diagnosed with GCA, and PMR features are present in up to half of biopsy-proven GCA cases. - Other conditions to exclude include crowned dens syndrome, hypothyroidism, obstructive sleep apnea, depression, and viral infections such as EBV or parvovirus B19. Source StatPearls "Polymyalgia Rheumatica" - disease-level clinical article Status traced to the source above Rx: Main treatment | IL-6 receptor blocker for relapsing PMR or an impossible steroid taper - rheumatology-initiated | Bone protection on long-term steroid - calcium with vitamin D MAIN TREATMENT - choose one, plus any add-on marked below 1. PREDNISOLONE [1st line] Adult 15 mg once daily in morning with breakfast for 3-4 weeks (until symptoms resolve and ESR/CRP normalize), then taper by 2.5 mg every 2-4 weeks to 10 mg/day, then by 1 mg monthly - long-term (1-2 years tapering course) Peds Adult-only condition - paediatric section not applicable Source BSR/BHPR Guideline for Polymyalgia Rheumatica for the regimen, with the dose from Egyptian National Drug Formulary - Endocrine System Drugs 2024, Prednisolone monograph (printed pages 169-170): "Oral: Usual Initial doses: 5 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses." and "Abrupt withdrawal is not recommended particularly with doses 40 mg or more or 3 weeks of treatment or more." The formulary states a general adult range rather than a polymyalgia regimen; the 15 mg start and the taper are from the BSR/BHPR guideline, which is not held in this corpus. Why Rapid symptomatic relief within 48-72 hours confirms diagnosis; exclude Giant Cell Arteritis Caution ALWAYS screen for Giant Cell Arteritis (headache, jaw claudication, visual loss); GCA is a medical emergency requiring high-dose steroids (40-60 mg daily). Co-prescribe bone protection (bisphosphonate + calcium/vitamin D) and PPI gastroprotection. Never stop steroids abruptly (risk of adrenal crisis). Monitor blood pressure, blood glucose, weight, and bone density during long-term therapy. Egypt HOSTACORTIN H 5MG 30 TAB. SANOFI 12.00 EGP (0.40/unit) PREDNISOLONE 5 MG 20 TABS. ARAB DRUG COM... 24.00 EGP (1.20/unit) PREDILONE 5MG 10 TAB. (25 STRIPS PACK) KAHIRA 250.00 EGP (25.00/unit) EPICOPRED 5 MG 30 ORODISPERSIBLE TABS. EIPICO 69.00 EGP PREDNISOLONE-EVA 5 MG 30 ORODISPERSIBLE TABS. EVA PHARMA 79.50 EGP DISPRELONE-OD 5 MG 30 ORODISPERSABLE TABS. ANDALOUS PHARMA 84.00 EGP SOLUPRED ORO 5 MG 30 ORODISPERSIBLE TABS. SANOFI WINTHROP > SANOFI 84.00 EGP ACETASEE 1% EYE DROPS (SUSP.) 5 ML RAMEDA 7.50 EGP -> ? strength differs, ? different route - not oral solid PREDNIS 5MG/5ML SYRUP 100 ML PHAROPHARMA 9.50 EGP -> ? strength differs, ? different route - not oral solid 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Peds Adult-only condition - paediatric section not applicable Source Polymyalgia Rheumatica - disease-level clinical article (polymyalgia-rheumatica- referral-full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - The GCA (giant cell arteritis) red flags requiring urgent evaluation are new headache, visual or jaw symptoms, temporal artery tenderness or pulse loss, persistent inflammatory markers, high-grade fever, and refractory symptoms. RED FLAG - The rheumatology referral criteria are atypical features, inadequate response to initial GC treatment, prominent peripheral arthritis, and tapering difficulty. 3. METHOTREXATE [add-on - not a substitute] Adult 7.5 to 10 mg/week Peds Adult-only condition - paediatric section not applicable Source Polymyalgia rheumatica (PMR referral & management) - disease-level clinical article (polymyalgia-rheumatica-referral-clinical.txt) Why Steroid-sparing immunosuppressive adjunct for PMR patients at high risk of relapse or prolonged glucocorticoid therapy. Caution Monitor blood counts and renal and liver function. Methotrexate 2.5 mg Tablets SmPC section 4.4 (eMC product 511) says "Before beginning or reinstituting methotrexate after a rest period, the patient's renal, liver and bone marrow function should be assessed by history, physical examination and laboratory tests", and "Full blood count (including haematocrit), hepatic and renal function tests (including urinalysis) should be carried out every week until treatment is stabilized, thereafter every 2 to 3 months throughout treatment". Co-prescribe folic acid to reduce toxicity. Methotrexate 2.5 mg Tablets SmPC section 4.4 (eMC product 511) says "In patients with rheumatoid arthritis or psoriasis, folic acid or folinic acid supplementation may reduce methotrexate toxicity, such as gastrointestinal symptoms, stomatitis, alopecia and elevated liver enzymes", and adds "It is recommended to check levels of vitamin B12 prior to initiating folic acid supplementation, particularly in adults aged over 50 years, as folic acid intake may mask a vitamin B12 deficiency". CONTRAINDICATED, from the same label section 4.3: methotrexate is barred where hepatic function is significantly impaired; where renal function is severely or significantly impaired - a creatinine clearance under 30 ml/min - at doses below 100 mg/m2, and where renal impairment is moderate - a clearance under 60 ml/min - at doses above 100 mg/m2; and in liver disease, fibrosis and cirrhosis included, or recent or active hepatitis. It is teratogenic, and should not be given in pregnancy or to a mother who is breast- feeding. Egypt METHOTREXATE 2.5MG 100 TAB (ORION) ORION PHARMA-FINLAND > S.... 130.25 EGP (1.30/unit) METHOTREXATE 2.5MG 30 TAB. (ORION) ORION PHARMA-FINLAND > S.... 84.00 EGP (2.80/unit) METHOTREXATE (ACDIMA) 2.5MG 100 TABS. SHANGHAI SINE PHARMACE... 333.50 EGP (3.33/unit) IMUTREXATE 2.5 MG 10 TABS. EVA PHARMA 51.00 EGP (5.10/unit) IMUTREXATE 5 MG 10 TABS. EVA PHARMA 77.00 EGP (7.70/unit) IMUTREXATE 7.5 MG 10 TABS. EVA PHARMA 89.00 EGP (8.90/unit) IMUTREXATE 10 MG 10 TABS. EVA PHARMA 100.00 EGP (10.00/unit) IMUTREXATE 15 MG 10 TABS. EVA PHARMA 136.00 EGP (13.60/unit) IL-6 RECEPTOR BLOCKER FOR RELAPSING PMR OR AN IMPOSSIBLE STEROID TAPER - RHEUMATOLOGY-INITIATED 4. SARILUMAB [3rd line] Adult 200 mg subcutaneously every two weeks, and the steroid comes down alongside it. US label verbatim: "The recommended dosage of KEVZARA is 200 mg once every two weeks given as a subcutaneous injection, in combination with a tapering course of systemic corticosteroids. KEVZARA can be used as monotherapy following discontinuation of corticosteroids." The label stops it rather than reducing it if the blood tests turn: "Discontinue KEVZARA if the patient develops neutropenia (using ANC results obtained at the end of the dosing interval), thrombocytopenia, or liver enzyme abnormalities." - Continued while the steroid is being withdrawn, then reviewed. The label's own framing is that it can carry on as monotherapy "following discontinuation of corticosteroids", so the end point is a patient off prednisolone rather than a fixed number of weeks. Peds Adult-only condition - paediatric section not applicable Source KEVZARA (sarilumab) injection US prescribing information, boxed warning, section 1.2 Polymyalgia Rheumatica, section 2.1 General Considerations Prior to Administration and section 2.3 Recommended Dosage for Polymyalgia Rheumatica (DailyMed SetID 827bc01c-d379-4266-a18c-c7f904b76af3) Why The disease article names the drug and the exact patient, verbatim: "Sarilumab is a biologic medication approved for treating polymyalgia rheumatica in adults who have not responded adequately to corticosteroids or cannot tolerate corticosteroid tapers." The US label's indication section names the same disease in almost the same words, verbatim: "KEVZARA is indicated for treatment of adult patients with polymyalgia rheumatica who have had an inadequate response to corticosteroids or who cannot tolerate corticosteroid taper." The card carried prednisolone and methotrexate; sarilumab is the only drug licensed for this disease by name, and it is the one the article reaches for when the taper fails. Egypt registers KEVZARA 200 mg pre-filled syringes at about 14,050 EGP for two, so cost is part of the conversation. Rheumatology starts it; the regimen is printed so a shared-care clinic can recognise it and knows to hold it during infection. Caution RED FLAG - boxed warning, serious infection. US label verbatim: "Patients treated with KEVZARA are at increased risk for developing serious infections that may lead to hospitalization or death. Opportunistic infections have also been reported in patients receiving KEVZARA. Most patients who developed infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. Avoid use of KEVZARA in patients with an active infection." That last clause matters here because almost every patient on this card is also on prednisolone. Tuberculosis is screened for before the first injection, not after. US label verbatim: "Prior to initiating KEVZARA, test patients for active and latent tuberculosis (TB). KEVZARA should not be administered to patients with active TB. If positive for latent infection, consider treating for TB prior to KEVZARA use." The boxed warning adds that TB "may present with pulmonary or extrapulmonary disease". Latent tuberculosis is common in Egypt. Baseline bloods gate the first dose. US label verbatim: "Treatment initiation with KEVZARA is not recommended in patients with an absolute neutrophil count (ANC) below 2000 per mm3, or platelet count below 150,000 per mm3." and "Treatment initiation with KEVZARA is not recommended in patients with or who have alanine transaminase (ALT) or aspartate aminotransferase (AST) above 1.5 times the upper limit of normal (ULN)." Lipids are measured at baseline too. IL-6 blockade blunts the inflammatory markers you would otherwise use to judge the disease and to detect infection. A normal CRP on this drug does not exclude sepsis, and the fever may be absent. Not to be stacked on another biologic. US label verbatim: "Avoid using KEVZARA with biological DMARDs because of the possibility of increased immunosuppression and increased risk of infection." The steroid-related work does not stop. Disease article verbatim: "Vitamin D and calcium supplementation are routine recommendations for patients on long-term steroids. Bisphosphonate prophylaxis is recommended for patients in moderate to high fracture risk categories". New headache, jaw claudication or visual loss in a patient with polymyalgia is giant cell arteritis until proved otherwise, and that is a same-day, high-dose-steroid emergency - not a reason to bring the biologic forward. Egypt KEVZARA 200 MG 2 PRE-FILLED SYRINGES SANOFI > EGYPTIAN PHARMACEUTICAL TR... 14050.00 EGP BONE PROTECTION ON LONG-TERM STEROID - CALCIUM WITH VITAMIN D - give alongside 5. CALCIUM CARBONATE [add-on - not a substitute] Adult 600 mg of calcium (as calcium carbonate 1500 mg) with 400 IU vitamin D3, one combined tablet twice a day, morning and evening - For as long as the prednisolone course lasts Peds Adult-only condition - paediatric section not applicable Source Accrete D3 film-coated tablets SmPC sections 2 and 4.2 (eMC product 2766) - verbatim: "Each film-coated tablet contains 600 mg calcium (as calcium carbonate 1500 mg) and 10 micrograms of colecalciferol (equivalent to 400 IU vitamin D 3 )" and "One tablet twice a day (e.g. one tablet in the morning and one tablet in the evening)." Why Polymyalgia rheumatica is treated with a year or more of prednisolone, which strips bone from the start. Calcium with vitamin D is the floor of steroid bone protection and belongs on the card next to the steroid that causes the problem. Caution Egypt sells this mostly as a combined calcium-with-vitamin-D3 tablet; if plain calcium carbonate is used, vitamin D has to be given as well. Bone protection is not only calcium: assess fracture risk and add a bisphosphonate for anyone at moderate or high risk, which most patients on a long steroid course will be. Do not use it where calcium is already high or being lost in the urine - myeloma, bone metastases, sarcoidosis, primary hyperparathyroidism. Check serum calcium and creatinine periodically on long treatment, especially in a patient also on a thiazide or digoxin. Calcium blocks tetracycline absorption - give a tetracycline well before the calcium dose, or several hours after it. Egypt OKTAL 600 MG 30 TABS. INTERNATIONAL... 31.20 EGP (1.04/unit) USKADE 600 MG 30 TABS. HOCHSTER PHAR... 36.00 EGP (1.20/unit) CALCINEX PLUS SYRUP 120 ML FAMILY PHARMA... 59.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)