Polymyalgia (PMR)

• General Rheumatology consultations (consultants, specialty doctors, specialist nurses, ANP, senior Pharmacist)
• AHP (Rheumatology Physiotherapy, Podiatry, Occupational Therapy)
• US scan of the joints (for internal referrals only)
• Intraarticular steroid injections (for internal referrals only or performed by Rheumatology Physiotherapist)
• Training for self-delivered subcutaneous injections (internal use only)
• Medical Day Unit (internal service for delivery of intravenous medication, subcutaneous medication, Short Synacthen test)
• Rheumatology on-call (quick access to the service, prompt reply to enquiries via email)
• Rheumatology page 1439 – covered by resident doctor
• Rheumatology helpline  - 01292513316 – Service run by Rheumatology Specialist nurses.

Polymyalgia rheumatica is a condition that can be diagnosed and managed in primary care.

If there is diagnostic uncertainty then please refer or consider A&G.

Rheumatology input may be needed in the following circumstances (see next section)

Atypical features or features that increase likelihood of a non-PMR diagnosis:

• 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
• Treatment dilemmas such as:
  • Incomplete, poorly sustained or non-response to corticosteroids
  • Inability to reduce corticosteroids
  • Contraindications to corticosteroid therapy
  • The need for prolonged corticosteroid therapy (>2 years)

Refer to Rheumatology with urgent priority if the patient displays persistent symptoms as above, by using SCI OP Gateway

Do not refer patients with typical presentation (age more than 50 with bilateral shoulder or hip pain lasting more than 2 weeks associated with early morning stiffness and elevated inflammatory markers) who have a complete sustained response to low dose corticosteroids.

Do not send new referrals only for updates or to ask for urgent review do to flares for patients already known to rheumatology, being on the list waiting for reviews, as we cancel such referrals to avoid duplication.

Please do not hesitate to keep in touch with us regarding your patients with any updates, symptom changes or flare ups using the Rheumatology Clinical email inbox: clinicalr@aapct.scot.nhs.uk

Before referring to rheumatology please check FBC, ESR, CRP, and Rheumatoid factor.

In the body of referral, the referrer should present the clinical assessment of peripheral joints, as some patients could develop overlap with rheumatoid arthritis.

The referrer should ask about GCA symptoms for patients with a PMR query.

Steroid reduction in Polymyalgia Rheumatica: Prednisolone 15mg for 3-4 weeks, then reduce by 2.5mgs every 2 weeks till on 10 mg daily, thereafter reduction by 1mg every month until complete discontinuation. In case of symptom relapse, please re-check ESR and CRP. If they return elevated you should increase prednisolone one step up or to the dose that controlled symptoms and then reduce slower by 1mg every 6-8 weeks’ interval.

This is the theoretical pace of steroid reduction, we adapt this based on individual patient particularities (disease evolution, tolerance, progress, associated morbidities) and consultant’s experience.

When patients remain on steroids for over 3 months, on doses >7.5mg daily, they must organize dental review prior starting on treatment with bisphosphonates to prevent steroid induced osteoporosis through alendronic acid 70mg once weekly and Adcal bd, if there are no contraindications.

1. British Society for Rheumatology Adult Rheumatology Referral Guidance. September 2021. Accessed at: https://www.rheumatology.org.uk/Portals/0/Documents/Policy/Adult-rheumatology-referral-guidance.pdf?ver=2022-08-04-104812-413
2. NHS Lanarkshire Rheumatology referral guidelines. March 2022. Accessed at: https://rightdecisions.scot.nhs.uk/media/2014/ebooklet-rheumatology-referrals-2022.pdf
3. NHS Lothian. RefHep. Accessed at:RefHelp – Instant Acces s to Referral Guidelines for Lothian