Symptoms and Treatment of Polymyalgia Rheumatica (PMR)
Polymyalgia rheumatica (PMR) presents primarily with bilateral shoulder and hip girdle pain with morning stiffness, and is treated with glucocorticoids at an initial dose of 12.5-25 mg prednisone daily with a structured tapering regimen.
Symptoms of PMR
Characteristic Clinical Presentation
- Core symptoms:
- Bilateral shoulder pain and stiffness (most common presentation)
- Bilateral hip girdle pain and stiffness
- Pronounced morning stiffness lasting >45 minutes
- Neck pain and limited range of motion
- Acute or subacute onset (symptoms developing over days to weeks) 1
Associated Symptoms
- Fatigue
- Low-grade fever
- Weight loss
- Malaise
- Decreased appetite 1
Laboratory Findings
- Elevated inflammatory markers:
- Normal creatine kinase (CK) levels (helps differentiate from myositis)
- Negative rheumatoid factor and anti-CCP antibodies (helps rule out rheumatoid arthritis) 2
Risk Factors
- Age >50 years (average age of onset: 73 years)
- Female sex (2-3 times more common in women)
- Northern European descent 4, 1
Treatment of PMR
First-Line Treatment: Glucocorticoids
Initial dosing:
Tapering regimen:
- Reduce to 10 mg/day within 4-8 weeks
- Then gradually taper by 1 mg every 4 weeks until discontinuation
- Avoid rapid tapering (>1 mg/month) as it increases relapse risk 3
Response monitoring:
- Clinical improvement typically occurs within 24-48 hours
- If no response within 1 week, reconsider diagnosis
- Monitor ESR and CRP to assess disease activity 3
Second-Line Treatment: Methotrexate
Indications for methotrexate:
- Insufficient response to glucocorticoids
- Relapse during glucocorticoid tapering
- Patients experiencing glucocorticoid-related adverse events
- High-risk patients (female sex, peripheral inflammatory arthritis, comorbidities) 3
Dosing:
- 7.5-10 mg/week orally
- Higher doses (up to 25 mg/week) for more severe cases
- Supplement with folate to reduce side effects 3
Monitoring:
- Clinical improvement typically begins after 2 weeks
- Almost complete response expected after 4 weeks
- Regular liver function tests and complete blood counts 3
Management of Relapses
- If relapse occurs during tapering:
- Increase prednisone dose to pre-relapse dose
- When symptoms are controlled, gradually decrease to the dose at which relapse occurred
- Resume slower tapering 3
Treatments Not Recommended
- TNFα blocking agents (strongly discouraged) 3
- NSAIDs as primary treatment (may be used short-term for pain related to other conditions) 3
- Chinese herbal preparations (Yanghe herb decoction, Biqi capsules) due to unclear efficacy and safety 2
Follow-up and Monitoring
- Every 4-8 weeks in the first year
- Every 8-12 weeks in the second year
- More frequent monitoring during tapering or relapse
- Monitor for:
- Disease activity (symptoms)
- Laboratory markers (ESR, CRP)
- Glucocorticoid-related side effects 3
Special Considerations
Giant Cell Arteritis (GCA):
- Occurs in approximately 20% of PMR patients
- Requires higher glucocorticoid doses and more aggressive treatment 4
- Watch for new headache, jaw claudication, visual disturbances
Risk factors for relapse:
- Female sex
- High ESR (>40 mm/1st hour)
- Peripheral inflammatory arthritis 3
Conditions requiring specialist referral:
- Atypical presentation
- High risk of therapy-related side effects
- PMR refractory to glucocorticoid therapy
- Relapses or need for prolonged therapy 3
Non-Pharmacological Management
- Individualized exercise program to maintain muscle mass and function
- Fall prevention strategies, particularly important for frail patients 3
PMR typically lasts 2-3 years but may persist longer in some patients, requiring careful monitoring and management of both disease activity and treatment-related complications 4.