From the Guidelines
Initial investigations for polymyalgia rheumatica (PMR) should include erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which are typically elevated, along with a complete blood count, liver function tests, renal function tests, thyroid function tests, creatine kinase, and rheumatoid factor/anti-CCP antibodies to exclude other conditions, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1. The mainstay of treatment is low-dose oral prednisolone, with the initial dose depending on the patient's risk of relapse and side effects, but generally within the range of 12.5–25 mg prednisone equivalent daily, as conditionally recommended by the panel 1. Some key points to consider in the management of PMR include:
- Assessing comorbidities and risk factors for steroid-related side effects, such as hypertension, diabetes, and osteoporosis, before initiating therapy 1
- Using the minimum effective dose of glucocorticoids (GCs) and tapering gradually to minimize side effects, with a suggested initial tapering to 10 mg/day prednisone equivalent within 4–8 weeks 1
- Considering the use of methotrexate (MTX) in addition to GCs, particularly in patients at high risk for relapse or with significant comorbidities, as conditionally recommended by the panel 1
- Monitoring for steroid side effects, including diabetes, hypertension, and osteoporosis, and adjusting the treatment plan as needed 1
- Regular follow-up, every 4–8 weeks in the first year and every 8–12 weeks in the second year, to assess response and guide tapering, as suggested by the group 1 It is essential to individualize the treatment plan based on the patient's specific needs and risk factors, and to consider referral to a specialist if the diagnosis is uncertain or if the patient is not responding to treatment, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.
From the Research
Initial Investigations for Polymyalgia Rheumatica (PMR)
- Diagnosis is made on the basis of a combination of clinical and laboratory findings 2
- Patients typically present with shoulder and hip girdle pain with pronounced stiffness 2
- Inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are usually elevated 2, 3
- An ultrasound and MRI of the shoulder and hip can be done to localise inflamed tissues 2, 4
Treatment for Polymyalgia Rheumatica (PMR)
- Corticosteroids constitute the cornerstone therapy in the management of patients with PMR 5
- An initial dose of prednisone of 10-20 mg/day yields clinical improvement in the majority of patients with PMR 5
- Treatment with low dose prednisone should be considered, with an initial dose of 12.5-25 mg prednisone equivalent daily 4
- Methotrexate is the most commonly used corticosteroid sparing agent 5
- Osteoporosis prophylaxis is also recommended 5
- Treatment duration is typically 2-3 years but may be longer 4