Polymyalgia Rheumatica (PMR)
NHS Tayside RefGuide
Referring to secondary care
Most cases can be managed in primary care. Consider seeking advice from rheumatology if:
- Atypical presentation or uncertainty about diagnosis
- Failure to respond to prednisolone 15mg daily
- Difficulty reducing prednisolone dose below 5mg daily
- >2 relapses (as DMARDs may need to be considered)
- Features of other rheumatic disease eg. peripheral joint swelling.
Background
PMR is the most common inflammatory rheumatic disease in the elderly. It has an association with Giant Cell Arteritis (GCA), the management of which is covered here.
History and examination
Diagnosis of PMR should be based on the following inclusion and exclusion criteria.
Urgent institution of steroid therapy is not necessary and can be delayed to allow investigation.
| Inclusion criteria | Exclusion criteria |
| Age >50 years | Active or chronic infection |
| Duration > 2 weeks | Active cancer |
| Abrupt onset | |
| Symmetrical shoulder and/or pelvic girdle aching | |
| Morning stiffness duration of >45 minutes | |
| Evidence of inflammation (raised PV and CRP) |
Presence of the following makes the diagnosis of PMR less likely:
- Age <60 years
- Chronic onset (>2 months)
- Lack of shoulder involvement
- Lack of inflammatory stiffness
- Prominent systemic features, weight loss, night pain, neurological signs
- Features of other rheumatic disease
- Normal or extremely high acute-phase response
- Drug-induced myalgia
- Chronic pain syndromes
- Endocrine disease
- Neurological conditions eg Parkinson’s disease.
Investigations
Laboratory investigations should include the following to support a diagnosis of PMR and exclude other potential mimics:
- Full blood count
- CRP (and PV)
- Urea and electrolytes
- Liver function tests
- Bone profile
- Myeloma screen
- TSH
- Glucose (baseline in case of starting steroids)
- Creatine kinase (CK).
Exclude concomitant GCA
If PMR is diagnosed, it is important to exclude concomitant GCA as this requires urgent treatment with high dose steroids (See separate guidance).
Management
- Glucocorticoids
- Give oral steroids in reducing regime
- The majority of patients have a dramatic improvement in their symptoms within 1 week
- There should be normalisation of inflammatory markers within 4 weeks. In asymptomatic patients, inflammatory markers do not need to be checked routinely thereafter
- I/M Depomedrone injections every 3-4 weeks can be used in mild cases or where a contraindication to oral steroids exists. Start with 120mg and reduce by 20mg every 2-3 months.
- Osteoporosis prophylaxis
Osteoporosis prophylaxis should be considered in any patient commencing glucocorticoids. Fracture risk can be calculated here and there is a link to NOGG guidance once fracture risk has been calculated; this gives useful advice regarding need for DEXA scanning and treatment.
- Review appointments
The following should be assessed when reviewing a patient who is being treated for PMR:
- Response to treatment: proximal pain, fatigue, morning stiffness (differentiate between symptoms due to inflammation and co-existing degenerative problems eg rotator cuff tears, osteoarthritis)
- Complications of disease: symptoms of GCA (see separate guidance)
- Steroid-related adverse events eg diabetes, osteoporotic risk
- Atypical features or those suggesting an alternative diagnosis
Suggested follow up schedule (BSR guidelines):
- Week 0
- Week 1-3
- Week 6
- Months 3, 6, 9, 12
- Relapses
Defined as a recurrence of symptoms, not just an unexplained rise in inflammatory markers.
- If clinical features of GCA – see see separate guidance
- If clinical features of PMR – increase prednisolone to dose at which patient was asymptomatic. Single I/M injection of depomedrone can also be used.