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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

 

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