Management of Right-Sided Myalgia
Glucocorticoid therapy is the first-line treatment for right-sided myalgia when polymyalgia rheumatica is suspected, with a recommended initial dose of 12.5-25 mg prednisone equivalent daily, individualized based on risk factors for relapse and side effects. 1, 2
Initial Assessment and Diagnosis
- Conduct a comprehensive laboratory assessment to exclude mimicking conditions, including rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies (ACPA), C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR), complete blood count, glucose, creatinine, liver function tests, and bone profile 1, 2
- Consider additional investigations based on clinical presentation, such as protein electrophoresis, thyroid stimulating hormone (TSH), creatine kinase, and vitamin D levels 1
- Evaluate for potential underlying causes of myalgia, including structural/mechanical factors (scoliosis, joint hypomobility), metabolic factors (iron deficiency, hypothyroidism, vitamin D deficiency), and medication-induced myopathy 3, 4
Treatment Approach for Polymyalgia Rheumatica
First-Line Therapy
- Start with prednisone 12.5-25 mg daily, with dose selection based on individual risk factors 1, 2
- Avoid initial doses ≤7.5 mg/day or >30 mg/day 1
Glucocorticoid Tapering
- Initial tapering: Reduce dose to 10 mg/day prednisone equivalent within 4-8 weeks 1
- Once remission is achieved: Taper by 1 mg every 4 weeks until discontinuation 1, 5
- For relapse: Increase to pre-relapse dose and decrease gradually (within 4-8 weeks) to the dose at which relapse occurred 1, 5
Alternative Approaches
- Consider intramuscular methylprednisolone as an alternative to oral glucocorticoids 1
- For patients with frequent relapses or glucocorticoid-related side effects, consider adding methotrexate as a steroid-sparing agent 5
Management of Fibromyalgia-Related Myalgia
Focus on non-pharmacological modalities as first-line treatment 1:
Pharmacological options for fibromyalgia (if non-pharmacological approaches are insufficient):
Management of Other Myalgia Types
- For myofascial pain syndrome: Focus on identifying and treating trigger points, addressing underlying mechanical factors, and physical therapy to restore normal neuromuscular function 3, 7
- For drug-induced myalgia: Consider discontinuing the offending medication and switching to an alternative 4
- For symptomatic relief of myalgic pain: Consider pregabalin, gabapentin, or amitriptyline 6
- For myalgia with muscle cramps: Consider carbamazepine or phenytoin 6
- For mild to moderate pain: Ibuprofen 400 mg every 4-6 hours as needed, not exceeding 3200 mg total daily dose 8
Follow-up and Monitoring
- Schedule follow-up visits every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as indicated for relapse or during glucocorticoid tapering 1, 2
- Monitor for glucocorticoid-related side effects, comorbidities, and risk factors for relapse 1, 2
- Document a minimal clinical and laboratory dataset during follow-up 1
Special Considerations
- Consider specialist referral for atypical presentations (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years) 1, 2
- Female patients may have higher risk of glucocorticoid-related side effects 1, 2
- For persistent nighttime pain when reducing below 5 mg/day of prednisone, consider splitting the daily dose 5