“Every time we cut the steroids the stiffness comes straight back — I want to go back to the dose that worked”

Relapse during glucocorticoid tapering is common in polymyalgia rheumatica. A relapse is the return of PMR symptoms, usually with rising inflammatory markers; raised markers alone without symptoms are not a relapse. The BSR 2024 guideline advises, for a relapse, returning to the previous dose at which the person was well (rather than restarting the initial dose), then tapering more slowly, and referring to specialist care for relapsing disease, inability to taper, or prolonged steroid need, where steroid-sparing treatment (such as methotrexate, or a biologic in some cases) can be considered. Every relapse should prompt a GCA screen (new headache, scalp tenderness, jaw claudication, visual symptoms need same-day assessment) and reconsideration of alternative diagnoses (late-onset rheumatoid arthritis, infection, malignancy). Ask exactly how the person is taking their tablets: self-adjustment is common. Long-term glucocorticoids cause weight gain, hyperglycaemia, hypertension, skin thinning, sleep and mood disturbance, cataract and osteoporosis. Bone protection is recommended for most older people expected to take glucocorticoids for 3 months or more (NOGG guidance); if alendronate causes heartburn, check it is taken correctly and consider alternatives, and assess fracture risk. The National Patient Safety Alert on steroid emergency cards (2020) requires people at risk of adrenal insufficiency, including those on prednisolone 5 mg or more for 4 weeks or longer, to be given an NHS steroid emergency card and sick-day advice; steroids must never be stopped abruptly. Offer recommended vaccinations, including shingles vaccination (non-live) for eligible people. The communication task is respecting her lived experience of relapse and her caring role while negotiating a safer dose plan.