From the Guidelines
Polymyalgia rheumatica (PMR) should be diagnosed based on a combination of clinical symptoms, laboratory findings, and exclusion of other conditions, with diagnostic evaluation including ESR, CRP, RF, anti-CCP, and creatine kinase level, as well as X-rays and US of affected joints, and giant cell arteritis should be ruled out, as recommended by the most recent study 1. The diagnostic criteria for PMR include:
- Age over 50
- Bilateral shoulder and/or hip pain and stiffness lasting at least 2 weeks
- Elevated inflammatory markers (ESR >40 mm/hr or CRP >10 mg/L)
- Morning stiffness lasting more than 45 minutes
- Rapid response to low-dose glucocorticoids The gold standard treatment for PMR is oral prednisone, typically starting at 10-20 mg/day, as recommended by the most recent study 1. Patients usually experience dramatic improvement within 24-72 hours, which itself serves as a diagnostic confirmation. After 2-4 weeks of initial therapy with symptom control, the dose should be gradually tapered by 1-2.5 mg every 2-4 weeks to a maintenance dose of 5-7.5 mg daily, then more slowly over 1-2 years to prevent relapse. For patients with frequent relapses or requiring long-term steroids, methotrexate (10-15 mg weekly) may be added as a steroid-sparing agent, as recommended by previous studies 1. Regular monitoring of inflammatory markers, blood glucose, bone density, and blood pressure is essential during treatment due to steroid side effects. Calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation should be initiated with steroid therapy to prevent osteoporosis, and bisphosphonates may be indicated for those at high fracture risk. Patients should be monitored for symptoms of giant cell arteritis, including headache, jaw claudication, and visual disturbances, which represents a medical emergency requiring immediate higher-dose steroid treatment.
From the Research
Diagnostic Criteria for Polymyalgia Rheumatica (PMR)
- The diagnosis of PMR relies mainly on symptoms and signs combined with laboratory markers of inflammation 2
- Clinical symptoms include pain and morning stiffness in the shoulder and pelvic girdle, as well as general symptoms such as fatigue, fever, and weight loss 2, 3
- Laboratory markers of inflammation, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, are often elevated in PMR patients 4, 3
- Imaging modalities, including ultrasound, magnetic resonance imaging (MRI), and positron emission tomography with computed tomography (PET-CT), may be used to support the diagnosis, but are not yet widely available or fully validated 2, 3
Treatment for Polymyalgia Rheumatica (PMR)
- Glucocorticoid (GC) therapy is the primary treatment for PMR, with most patients responding promptly to 15-25 mg prednisolone per day 2
- The aim of treatment is to suppress symptoms and inflammation, while minimizing the risk of adverse effects from long-term GC use 4, 5
- Treatment duration and dose of GCs required for suppression of symptoms can vary significantly between patients, and may be influenced by factors such as initial response to therapy and disease duration 4
- Alternative treatments, such as disease-modifying antirheumatic drugs (DMARDs) and biologics, may be considered in patients who do not respond to GCs or who experience significant adverse effects 2, 5
Disease Monitoring and Relapse
- Regular monitoring of disease activity and inflammation markers is important to adjust treatment and prevent relapse 3, 5
- Relapses can occur, and patients with PMR may need to stay on GCs for extended periods, which can increase the risk of GC-related comorbidities such as diabetes and osteoporosis 2
- Imaging modalities, such as ultrasound and MRI, may be used to monitor disease activity and detect early signs of relapse 3