Polymyalgia Rheumatica

Question 1

What is polymyalgia rheumatica?

Answer 1

Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck.

There is a strong association to giant cell arteritis and the two conditions often occurs together

Both conditions respond well to treatment with steroids

Question 2

Demographics of polymyalgia rheumatica

Answer 2

It usually affects old adults (above 50 years)
More common in women
More common in caucasians

Question 3

Clinical features of polymyalgia rheumatica?

Answer 3

These should be present for at least 2 weeks:

Bilateral shoulder pain that may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning

Other features:

Systemic symptoms such as weight loss, fatigue, low grade fever and low mood
Upper arm tenderness
Carpel tunnel syndrome
Pitting oedema

Question 4

Differential diagnoses of polymalgia rheumatica?

Answer 4

The list of differentials is very long however some examples are:

Osteoarthritis
Rheumatoid arhtirits
Systemic lupus erythematosus
Myositis (from conditions like polymyositis or medications like statins)
Cervical spondylosis
Adhesive capsulitis of both shoulders
Hyper or hypothyroidism
Osteomalacia
Fibromyalgia

Question 5

Diagnosis of polymyalgia rheumatica?

Answer 5

mainly based on the clinical presentation and the response to steroids. Other conditions need to be excluded in order to make a diagnosis of PMR.

Inflammatory markers (ESR, plasma viscosity and CRP) are usually raised however normal inflammatory markers do not exclude PMR.

The NICE clinical knowledge summaries advise a number of investigations prior to starting steroids to exclude other conditions:

Full blood count
Urea and electrolytes
Liver function tests
Calcium can be raised in hyperparathyroidism or cancer or low in osteomalacia
Serum protein electrophoresis for myeloma and other protein disorders
Thyroid stimulating hormone for thyroid function
Creatine kinase for myositis
Rheumatoid factor for rheumatoid arthritis
Urine dipstick

Additional investigations to consider:

Anti-nuclear antibodies (ANA) for systemic lupus erythematosus
Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
Urine Bence Jones protein for myeloma
Chest xray for lung and mediastinal abnormalities

Question 6

Treatment guidelines for polymyalgia rheumatica

Answer 6

Treatment of PMR is with steroids. The NICE CKS have clear guidelines on the steroid regime you should follow if treating patients. This is a summary to help your understanding.

Initially patients are started on 15mg of prednisolone per day.

Assess 1 week after starting steroids. If there is a poor response in symptoms it is probably not PMR and an alternative diagnosis needs to be considered. Stop the steroids.

Assess 3-4 weeks after starting steroids. You would expect a 70% improvement in symptoms and inflammatory markers to return to normal to make a working diagnosis of PMR.

If 3-4 weeks of steroids has given a good response then start a reducing regime with the aim of getting the patient off steroids:

15mg until symptoms are fully controlled then
12.5mg for 3 weeks then
10mg for 4-6 weeks then
Reduce by 1mg every 4-8 weeks

If symptoms reoccur whilst on the reducing regime then they may need to increase the dose or stay on the dose longer before reducing again. It can take 1-2 years to fully wean off. If there is doubt about the diagnosis, difficulty controlling symptoms, difficult weaning steroids or steroids are required for more than 2 years refer to a rheumatologist.

Question 7

Management: Additional measures for patients on long term steroids.

Answer 7

You can use the mnemonic “Don’t STOP”:

DON’T – Make them aware that they will become steroid dependent after 3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn

S – Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”)

T – Treatment Card: Provide a steroid treatment card to alert others that they are steroid dependent in case they become unresponsive

O – Osteoporosis prevention: Consider osteoporosis prophylaxis whilst on steroids with bisphosphonates and calcium and vitamin D supplements

P – Proton pump inhibitor: Consider gastric protection with a proton pump inhibitor (e.g. omeprazole)