PMR

Interesting question, very valid.
I am a PA with 27 years of Rheumatology experience and a grandfather PA with 47 years of clinical practice. I have treated many PMR patients and find very few to be just alike. The clinical presentation often is similar, but not always. Labs often are helpful, but again, not always. I generally find that the patient holds the answer in response to treatment being started. PMR can be very elusive at times, that’s why clinical guidelines are just that, a set of principles determined by observations, yet not a black and white set of rules. Classic PMR can have a sudden onset. Go to bed fine, wake up hurting. These quickly respond to low dose steroids, 10.15 mg per day. The key in treating them is a gradual lowering of the dose from the dose amount that abated the Sx. Often the dose is 20 mg. At that point I lower the dose by 2.5 mg a day every 2-3 weeks, perhaps a month if needed. Dose lowering is always as tolerated by the patient, not a strict automatic. Once they get to 10 mg a day, I lower by 1 mg a month. Yes I monitor the markers, but my decision is based on patient perception and exam, primarily because comorbid conditions can affect the markers. I tell them they may be on some dose for up to a year. A DMARD often is started early to hasten the length of the steroid therapy. Failure to respond means either the Dx is not correct or you better look for cancer, which often masquerades as PMR. Finally, some PMR never goes away and requires doses of 1-3 mg per day to be stable. Test these waters every 3 months. It’s amazing how sensitive this condition is to small dose changes. This is what often confuses the primary care people who expect a quick fix. Finally, watch for early signs of RA, which can follow a PMR episode.
Don’t let your bias against steroids influence you too much. Yes, be cautious but follow the patient close enough to see what pattern is emerging.
All patients are unique which so tailor the approach to their response, not a set of guidelines or your fear of steroid use. Other Tx options such as biologic therapy should ofcourse be considered.
I have been fooled many times, you will be too.