Polymyalgia rheumatica

Signs and Symptoms

Polymyalgia rheumatic (PMR) is a chronic inflammatory disease of unknown aetiology which presents with pain and stiffness that is worst in the morning and particularly affects the shoulders and hips

Diagnostic criteria

Diagnosis of PMR should be made by building up a weight of evidence by

• establishing (and reassessing) inclusion / exclusion criteria
• assessing response to steroid

Core inclusion criteria are

• age over 50
• symptoms present for over 2 weeks
• bilateral shoulder and/or pelvic girdle aching
• morning stiffness lasting over 45 minutes
• raised inflammatory markers (this diagnosis is possible but very rare if normal inflammatory markers).
• symptomatic and biochemical response to steroid treatment

Core exclusion criteria are evidence of a differential diagnosis as described below

NB: steroids are potent anti-inflammatory agents and can mask symptoms from a range of diseases

Differential Diagnoses

• Seronegative inflammatory arthritis.
• Osteoarthritis
• Regional musculoskeletal shoulder problems e.g. rotator cuff syndromes
• active infection, cancer
• other inflammatory rheumatic diseases
• drug-induced myalgia
• chronic pain syndromes
• endocrine disease
• neurological conditions, e.g. Parkinson's disease or post-polio syndrome

GCA symptoms especially visual symptoms or jaw claudication

• FBC UE LFT
• ESR/CRP
• TFT
• CK and myeloma screen

Treatment regime – guide only – should be tailored to the patient, but treatment is for 1-2 years.

• Prednisolone
  • 15mg / day for 4 weeks; then
  • 12.5mg daily for 4 weeks; then
  • 10mg daily for 4-6 weeks; then
  • reduce by 1mg every 4-8 weeks or alternate day reductions
• NB. Using higher starting dose than 15mg is associated with more complications, and will make it more difficult to wean down steroids

Follow up at 2 weeks

Evidence in favour of PMR if

• patient reported global improvement in symptoms of over 70% within a week
• normalization of inflammatory markers within 4 weeks
• be vigilant of mimicking differential diagnoses as described above

Relapse

• Common but normally responds to restarting or increasing dose of steroid to the last effective dose.
• If the person has frequent relapses or it is not possible to taper the steroids, refer for specialist review to consider disease modifying anti-rheumatic drugs (DMARDs)
• Needs to be differentiated from non-inflammatory aches and pains and can be confused with corticosteroid withdrawal symptoms which can cause fatigue and myalgia, and an increase in OA symptoms – if in doubt use inflammatory markers as a guide

Refer if diagnostic uncertainty or difficult management.

Evidence

1. British Society of Rheumatology (BSR), British Health Professionals in Rheumatology (BHPR). BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology (Oxford) 2010; 49: 186-90.
2. Dasgupta B, Matteson EL, Maradit-Kremers H. Management guidelines and outcome measures in polymyalgia rheumatica (PMR). Clin Exp Rheumatol 2007; 25: S130-6.

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date:July 2016