Polymyalgia Rheumatica
- PMR is the commonest inflammatory rheumatic condition in the elderly
- Usually age > 60, occasionally age 50-60
- Female : male 3:1
Diagnosis of 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
Red Flags
Go to GCA guidelines
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 or adverse effects from corticosteroids
- steroid still needed after 2 years
- If it is not possible to reduce corticosteroids at reasonable intervals without relapse
Investigations
FBC UE LFT PV 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
- Provide patient with blue steroid card
- Bone protection – Assess and manage osteoporosis risk, including starting calcium and Vitamin D supplementation
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)
Useful information:
Patient leaflets: http://www.patient.info/bones-joints-muscles/polymylagia-rheumatica-leaflet
Polymyalgia Rheumatica and GCA UK , http://www.pmrgcauk.com
Versus Arthritis, http://www.versusarthritis.org
References
[1] Clinical knowledge Summaries ( CKS) Polymyalgia rheumatica?; Jan 2019
[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
Guidelines reviewed 16/12/2019
Next review due 16/12/2020
GP Sifter Dr B Wesson ( RMS GP Lead for Rheumatology)
Version 3.1