What are the symptoms and treatment options for polymyalgia rheumatica?

Polymyalgia Rheumatica: Symptoms and Treatment

Clinical Presentation

Polymyalgia rheumatica presents with bilateral proximal aching and morning stiffness affecting the shoulders, neck, and hip girdle in patients over 50 years of age. 1, 2

Cardinal Symptoms

• Bilateral shoulder pain and stiffness that is worse in the mornings, often the most prominent feature 3, 4
• Hip girdle and pelvic pain with morning stiffness, though not mandatory for diagnosis 2, 5
• Neck pain and stiffness as part of the proximal distribution 6, 5
• Morning stiffness lasting more than 45 minutes, typically severe enough to interfere with daily activities 3, 4

Associated Constitutional Symptoms

• Low-grade fever, malaise, and fatigue are common systemic manifestations 7, 4
• Poor appetite and weight loss may accompany the musculoskeletal symptoms 7
• Low mood and depression can develop secondary to the debilitating nature of the disease 6, 7

Important Clinical Caveat

Always screen for giant cell arteritis (GCA) at every visit, as up to 20% of PMR patients will have evidence of GCA, and 50% of GCA patients have PMR symptoms. 7 Ask specifically about:

• New-onset headaches 7
• Jaw claudication (pain with chewing) 7
• Visual disturbances or vision loss 7

If any GCA symptoms are present, urgent same-day rheumatology consultation is mandatory before initiating treatment. 7

Diagnostic Workup

Essential Laboratory Tests

Obtain inflammatory markers (ESR and/or CRP), rheumatoid factor, anti-CCP antibodies, complete blood count, glucose, creatinine, liver function tests, bone profile (calcium, alkaline phosphatase), and urinalysis to establish baseline and exclude mimicking conditions. 1, 2

• Elevated ESR and CRP are typical but not universal—a small proportion of patients have normal inflammatory markers 7, 4
• Rheumatoid factor and anti-CCP antibodies to exclude rheumatoid arthritis 1, 2
• Additional tests to consider: protein electrophoresis, TSH, creatine kinase, vitamin D 1

When to Consider Specialist Referral

Refer to rheumatology for atypical presentations: age <60 years, peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, or refractory disease. 1, 8

Treatment Protocol

Initial Glucocorticoid Therapy

Start prednisone at 12.5-25 mg daily as first-line therapy; NSAIDs alone are inadequate for PMR treatment. 1, 2, 8

• Use 20-25 mg daily for patients with high relapse risk (female sex, ESR >40 mm/hr, peripheral arthritis) and low adverse event risk 8
• Use 12.5-15 mg daily for patients with significant comorbidities (diabetes, osteoporosis, hypertension, cardiovascular disease, glaucoma risk) 1, 8

Glucocorticoid Tapering Schedule

Reduce to 10 mg/day within 4-8 weeks if symptoms are controlled, then decrease by 1 mg every 4 weeks until discontinuation. 1, 8

Alternative tapering: Use alternating-day schedules (e.g., 10/7.5 mg every other day) for smoother transitions. 9, 8

Management of Relapses

For relapses on ≤5 mg prednisone, return to the previous effective dose, then taper more slowly (not exceeding 1 mg per month reduction). 9

• Temporarily increase glucocorticoid dose to re-establish control over 4-8 weeks 9
• Consider methotrexate as a corticosteroid-sparing agent for patients with multiple or prolonged relapses 9, 6
• Tocilizumab or secukinumab are promising alternatives for refractory cases 6

Monitoring Schedule

Follow-up every 4-8 weeks during year one, every 8-12 weeks during year two, and as needed for relapses or during tapering. 1, 8

At each visit, assess:

• Inflammatory markers (ESR, CRP) and clinical symptoms 9, 8
• Glucocorticoid-related adverse effects (hyperglycemia, hypertension, osteoporosis, cataracts, infections) 1, 8
• Screening for GCA symptoms (headache, jaw claudication, visual changes) 7
• Functional status, particularly upper extremity function and activities of daily living 6

Comorbidity Management

Assess and manage comorbidities before initiating glucocorticoids: hypertension, diabetes, osteoporosis (with recent fractures being particularly concerning), cardiovascular disease, peptic ulcer disease, cataracts, and glaucoma risk factors. 1, 2, 8

Female patients warrant closer monitoring as they have higher risk of both glucocorticoid side effects and disease relapse. 1, 8

Patient Education and Support

Provide education about PMR's impact, treatment effects including glucocorticoid risks, and recommend individually tailored exercise programs. 8

Ensure rapid access to medical advice for reporting flares or adverse events between scheduled visits. 1

Key Differential Diagnoses to Exclude

Monitor closely to differentiate from: elderly-onset rheumatoid arthritis (check for peripheral joint synovitis), inflammatory myositis (true weakness vs. pain-limited movement), bilateral shoulder capsulitis, spondyloarthritis, thyroid disease, malignancy, and Parkinson's disease. 2, 3, 7, 4

Treatment duration typically exceeds one year, and the disease course requires close monitoring with shared decision-making between patient and physician. 1, 8, 6