About Polymyalgia Rheumatica (PMR)

Polymyalgia Rheumatica is an inflammatory autoimmune articular and periarticular disease of the elderly.

  • Onset: >50 yo
    Mean age: 70 yo
  • F affected 2-3x more often than M
  • Alternative diagnosis should be strongly considered if no symptom relief with ≥20mg/d of prednisone.
  • Flares often occur if prednisone is tapered too rapidly.
  • Every visit, inquire about Giant Cell Arteritis (GCA) symptoms (vision loss, recurrent headaches, scalp tenderness, jaw claudication).
    • If GCA suspected, patient should be started on high dose prednisone (1mg/kg).
    • Temporal artery biopsy is gold standard for GCA diagnosis – prednisone should not be delayed for biopsy.
  • Symmetric stiffness -> pain  in neck, shoulders, hip girdle that is predominant in the morning
  • Improves with activity
  • Subacute onset over ~2-3 weeks
  • Systemic symptoms include malaise, fatigue, weight loss, fever
  • Physical exam:
    • Shoulders tender to palpation
    • ROM often limited due to stiffness > pain
    • Strength maybe limited by pain

Lab workup

  • No diagnostic labs
  • ESR and CRP typically significantly elevated 

Imaging

  • X-rays, MRI, u/s nonspecific
  • May show articular or periarticular inflammation

Response to Steroids

  • Significant improvement with prednisone 20mg/d
  • Worsening symptoms with  systemic steroids within 3-7 days excludes diagnosis
  • Early seronegative RA
  • Bursitis/tendinitis 
  • Spondyloarthropathy
  • Fibromyalgia 
  • Myositis (usually more weakness than pain, CK elevation) 
  • Hypothyroidism 
  • Malignancy (lymphoma, myeloma)
  • Osteoarthritis
  • Infection (TB, HIV, subacute bacterial endocarditis)
  • Prompt response to low dose prednisone (10-20mg/d) is highly characteristic of PMR 
    • Symptom reduction should be evident ~72 hours, usually within 24 hours 
  • Initial dose of prednisone should be maintained for at least 2-4 weeks with slow taper thereafter
    • 10-15mg/d range: Taper by 2.5mg/d every month 
    • ≤10mg/d: Taper by 1mg/d every month until off 
  • Second line therapy: sarilumab

Flares

  • Best identified by symptoms, ESR/CRP usually elevated
  • Escalate prednisone back to previous dose for flare
  • 75% of patient able to taper off steroids in 2 years

Monitor for Giant Cell Arteritis (GCA)

  • 15% of patients with PMR
  • GCA symptoms
    • Unilateral headache
    • Jaw claudication
    • Scalp tenderness
    • Vision loss