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Polymyalgia Rheumatica

·         PMR is the commonest inflammatory rheumatic condition in the elderly

·         Usually age > 60, occasionally age 50-60

·         Female : male    3:1

 

Diagnosisof PMR should be made by building up a weight of evidence by establishing (and reassessing) inclusion / exclusion criteria and assessing response to steroid

Core inclusion criteria;

·         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

·         symptomatic and biochemical response to steroid treatment

 

The diagnosis is possible but very rare if:

·         Age under 50

·         Normal inflammatory markers

 

Referral Criteria– atypical features

·         age < 60

·         chronic onset over 2m

·         no shoulder involvement

·         no inflammatory stiffness

·         prominent systemic features: weight loss / night pain / neuro signs

·         features of other rheumatological diseases

·         normal or extremely high inflammatory markers

·         patients with contraindications to steroid therapy

·         steroid still needed after 2 years

 

Investigations

FBC UE LFT ESR CRP TFT CK myeloma screen

CXR to exclude infection, inflammation or malignancy

Treatment

·         start prednisolone 15 - 20mg per day dependant on body weight

·         explain that the dose of prednisolone will be reduced gradually over several months but may have to be continued for 1-2 years

·         Bone protection – start calcium and vitamin D.  See osteoporosis guidance here (hyperlink)

 

Follow up at 4-6 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

 

 

Patient information here (patient.co.uk leaflet)

 

Red Flags

 

GCA symptoms especially visual symptoms or jaw claudication - present in 10% – go to guidelines

 

 

Differential diagnosis

·         musculoskeletal shoulder problems e.g. rotator cuff syndromes

·         active infection, cancer or giant cell arteritis (GCA)

·         other inflammatory rheumatic diseases

·         drug-induced myalgia

·         chronic pain syndromes

·         endocrine disease

·         neurological conditions, eg Parkinson's disease or post-polio syndrome

 

 

 

References

[1] Clinical Knowledge Summaries (CKS). Polymyalgia rheumatica. Version 1.0. Newcastle upon Tyne: CKS; 2009.

[2] Map of Medicine (MoM). London: MoM; 2010.

[3] 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.

[4] Dasgupta B, Matteson EL, Maradit-Kremers H. Management guidelines and outcome measures in polymyalgia rheumatica (PMR). Clin Exp Rheumatol 2007; 25: S130-6.

[5] Personal communication Drs Endean, Hutchinson. Rheumatology consultants Royal Cornwall Hospital May 2016