PMR Flashcards
What is Polymyalgia Rheumatica (PMR)?
Polymyalgia rheumatica (PMR) is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle, and neck, with a strong association with giant cell arteritis.
Who is most commonly affected by PMR?
PMR is more common in older white patients.
What is the typical onset of symptoms in PMR?
Symptoms typically develop rapidly over days to weeks and should be present for at least two weeks before a diagnosis of PMR is considered.
What are the core symptoms of PMR?
- Pain and stiffness in the shoulders (radiating to upper arms and elbows)
- Pain and stiffness in the pelvic girdle (radiating to thighs)
- Pain and stiffness in the neck
When do the symptoms of PMR tend to worsen?
- Worse in the morning
- Worse after rest or inactivity
- Interferes with sleep
- Takes at least 45 minutes to ease in the morning
- Improves somewhat with activity
What systemic symptoms can be associated with PMR?
- Weight loss
- Fatigue
- Low-grade fever
- Muscle tenderness
- Carpal tunnel syndrome
- Peripheral edema
What are some common differential diagnoses for PMR?
- Osteoarthritis
- Rheumatoid arthritis
- Systemic lupus erythematosus (SLE)
- Statin-induced myopathy
- Myositis (e.g., polymyositis)
- Cervical spondylosis
- Frozen shoulder
- Thyroid disorders
- Osteomalacia
- Fibromyalgia
- Lymphoma or leukaemia
- Myeloma
How is PMR diagnosed?
Diagnosis is based on clinical presentation, response to steroids, and excluding other conditions. Inflammatory markers like ESR and CRP are typically raised (but may be normal).
What investigations should be done before initiating steroid treatment for PMR?
- Full blood count
- Renal profile (U&E)
- Liver function tests
- Calcium levels
- Serum protein electrophoresis
- Thyroid-stimulating hormone
- Creatine kinase
- Rheumatoid factor
- Urine dipstick
Additional tests may include ANA, anti-CCP, urine Bence Jones protein, and chest X-ray.
What is the first-line treatment for PMR?
Prednisolone, starting at 15mg daily. Follow-up after 1 week to assess response.
How quickly do symptoms typically improve with steroid treatment in PMR?
Most patients experience at least a 70% improvement in symptoms within one week. Inflammatory markers return to normal within one month.
How is the steroid dose reduced over time for PMR?
- Start with 15mg daily until symptoms are fully controlled
- Reduce to 12.5mg for 3 weeks
- Reduce to 10mg for 4-6 weeks
- Gradually reduce by 1mg every 4-8 weeks as tolerated
What is the “Don’t STOP” mnemonic for managing long-term steroid use in PMR?
- Don’t: Avoid abrupt cessation to prevent adrenal crisis
- S: Sick day rules (increase steroids if unwell)
- T: Carry a steroid treatment card
- O: Osteoporosis prevention (bisphosphonates, calcium, vitamin D)
- P: Use proton pump inhibitors (e.g., omeprazole) for gastro-protection
