Polymyalgia rheumatica

• Polymyalgia rheumatica (PMR) is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. 
• There is a strong association with giant cell arteritis, and the two conditions often occur together.
• The cause is not fully understood. There are no relevant antibodies. It is more common in older white patients. Associated autoimmune disease.
• Presentation:

  • Relatively rapid onset of symptoms over days to weeks (should be present for 2 weeks before diagnosis is considered)
  • Pain and stiffness in:
  • Shoulders - potentially radiating to the upper arm and elbow
  • Pelvic girdle - potentially radiating to the thighs
  • Neck
• Characteristic features of pain and stiffness:

  • Worse in the morning
  • Worse after rest of inactivity
  • Interfere with sleep
  • Take at least 45 minutes to ease in the morning
  • Somewhat improve with activity
• Associated features:

  • Systemic symptoms - weight loss, fatigue and low grade fever
  • Muscle tenderness
  • Carpel tunnel syndrome
  • Peripheral oedema
• Diagnosis is based on clinical presentation, response to steroids and excluding differentials.
• Inflammatory markers (e.g., ESR and CRP) are usually raised (but may be normal).
• Investigations before starting steroids:

  • FBC
  • Renal profile U&Es
  • LFTs
  • Calcium - hyperparathyroid, cancer and osteomalacia as differentials
  • Serum protein electrophoresis for myeloma
  • TSH - thyroid disease as differential
  • Creatinine kinase for myositis
  • Rheumatoid factor for rheumatoid arthritis
  • Urine dipstick
• Additional investigations to consider:

  • Anti-nuclear antibodies (ANA) for systemic lupus erythematosus
  • Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
  • Urine Bence Jones protein for myeloma
  • Chest x-ray for lung and mediastinal abnormalities (e.g., lung cancer or lymphoma)
• Treatment of PMR is with steroids. The NICE clinical knowledge summaries recommend:

  • 15mg prednisolone daily initially
  • Follow up after 1 week
  • Patients with PMR have a dramatic improvement in symptoms within one week on steroids
  • Inflammatory markers return to normal within one month
  • Poor response to steroids suggests an alternative diagnosis
• Treatment with steroids typically lasts 1-2 years. NICE suggest the following reducing regime of prednisolone:

  • 15mg until the symptoms are fully controlled, then
  • 12.5mg for 3 weeks, then
  • 10mg for 4-6 weeks, then
  • Reducing by 1mg every 4-8 weeks
• Additional management for patients on long-term steroids can be remembered with the “Don’t STOP” mnemonic:

  • Don’t – steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
  • S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
  • T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
  • O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
  • P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)