Question

A 75-year-old woman is evaluated for a 2-week history of gradually increasing pain in both shoulders and hips; the pain radiates down both arms to the elbows and down both hamstrings to the knees. She reports no headache, jaw claudication, or vision changes. She was diagnosed with polymyalgia rheumatica 3 months ago. She started prednisone, 15 mg/d, with immediate and complete relief of symptoms; prednisone was weaned from 15 to 10 mg/d 2 months ago, then to 8 mg/d (current dose) 1 month ago. She remained asymptomatic until 2 weeks ago. She says that her current symptoms are just as bad as when she was first diagnosed. On physical examination, vital signs are normal; blood pressure is identical in both arms. There is no temporal tenderness or induration. Painful range of motion of both shoulders and hips is noted. Which of the following is the most appropriate management? A. Prednisone, 10 mg/d B. Prednisone, 30 mg/d C. Prednisone, 60 mg/d D. Prednisone, 20 mg/d, and methotrexate

Answer 1

Given the recurrence of symptoms while tapering prednisone, the most appropriate management for the 75-year-old woman with polymyalgia rheumatica would be to increase her prednisone to 30 mg/d, which is a significant yet not excessive dose adjustment. The correct option is B.

Step-by-step explanation:

A 75-year-old woman with a history of polymyalgia rheumatica (PMR) is experiencing a recurrence of pain after tapering her dose of prednisone. The fact that her symptoms returned with the decrease of prednisone suggests that the current dosage may be insufficient to control her inflammation.

The most appropriate management, considering there are no new symptoms such as headache, jaw claudication, or vision changes that might suggest giant cell arteritis, would be to increase her prednisone dose to manage her symptoms effectively.

In this scenario, choice A (prednisone, 10 mg/d) may not be sufficient, given she was symptomatic at 8 mg/d. Choice C (prednisone, 60 mg/d) is likely too high for an immediate increase without severe or vision-threatening symptoms.

Choice D (prednisone, 20 mg/d, and methotrexate) introduces a new medication, which is typically considered when there is a desire to spare steroids or in cases of refractory PMR. The correct option is B.