What are the signs and symptoms, diagnosis, and treatment of Polymyalgia Rheumatica (PMR)?

Polymyalgia Rheumatica: Signs, Symptoms, Diagnosis, and Treatment

Clinical Presentation

PMR presents with bilateral shoulder pain and morning stiffness in patients over 60 years old, typically with dramatically elevated inflammatory markers. 1

Key Signs and Symptoms:

• Bilateral shoulder girdle pain with severe morning stiffness (hallmark feature) 2
• Neck and hip girdle involvement (though hip involvement is not mandatory for diagnosis) 3, 2
• Age >60 years (average onset 73 years) 4
• Acute or subacute onset of symptoms 4
• Possible hand and knee swelling 1

Red Flags for Atypical Presentation (Requiring Specialist Referral):

• Age <60 years 1
• Peripheral inflammatory arthritis 1
• Systemic symptoms 1
• Low or normal inflammatory markers 1

Diagnostic Workup

Start with ESR and CRP measurement—both are elevated in >90% of PMR cases, with ESR being the preferred long-term monitoring marker. 5, 4

Essential Laboratory Tests:

• ESR and CRP (typically markedly elevated; ESR >40 mm/hr associated with higher relapse risk) 1, 5, 6
• Rheumatoid factor and anti-CCP antibodies to exclude rheumatoid arthritis 3
• Creatine kinase (CK) to rule out inflammatory myositis 1

Additional Testing to Exclude Mimics:

• Antinuclear antibodies (ANA) 1
• ANCA or tuberculosis tests if clinically indicated 1
• Chest radiographs at physician discretion 1

Imaging Considerations:

• Ultrasound of affected joints can aid diagnosis 1, 4
• MRI may be helpful in uncertain cases 4

Comorbidity Assessment Before Starting Glucocorticoids:

• Hypertension, diabetes, glucose intolerance 1, 3
• Cardiovascular disease, dyslipidemia 1, 3
• Osteoporosis (particularly recent fractures) 1, 3
• Peptic ulcer disease 1, 3
• Cataracts or glaucoma risk factors 1
• Chronic or recurrent infections 1

Note: Female sex is associated with higher risk of both glucocorticoid side effects and disease relapse. 1, 3

Treatment

Initiate prednisone at 12.5-25 mg daily—this is the evidence-based starting range that balances efficacy with safety. 1, 3

Initial Dosing Strategy:

• Use 12.5-25 mg prednisone equivalent daily as starting dose 1
• Choose higher end (20-25 mg) for patients with high relapse risk (female sex, ESR >40 mm/hr, peripheral arthritis) and low adverse event risk 1, 3
• Choose lower end (12.5-15 mg) for patients with diabetes, osteoporosis, glaucoma, or other glucocorticoid risk factors 1
• Never use initial doses ≤7.5 mg/day (inadequate) or >30 mg/day (excessive adverse effects) 1

Tapering Protocol:

Phase 1 (Initial Tapering):

• Taper to 10 mg/day within 4-8 weeks 1

Phase 2 (Slow Tapering):

• Decrease by 1 mg every 4 weeks (or 1.25 mg using alternate-day schedules like 10/7.5 mg) until discontinuation 1
• Tapering slower than 1 mg/month reduces relapse rates 7

Relapse Management:

• Increase to pre-relapse dose 1
• Gradually decrease back to the dose where relapse occurred over 4-8 weeks 1

Alternative Glucocorticoid Formulations:

• Intramuscular methylprednisolone (120 mg every 3 weeks) is an acceptable alternative to oral prednisone 1
• Modified-release prednisone (10 mg at bedtime) may provide better IL-6 suppression than morning dosing 8
• Single daily dose preferred over divided doses, except for prominent night pain during low-dose tapering 1

Glucocorticoid-Sparing Agents:

Consider methotrexate early in specific situations: 1

• Relapses or prolonged therapy anticipated 1
• High risk of glucocorticoid-related adverse effects 1
• PMR refractory to glucocorticoid therapy 1

Methotrexate dosing: 10 mg/week or higher shows efficacy 7

NSAIDs:

Do NOT use NSAIDs as primary treatment for PMR—glucocorticoids are strongly preferred. 1

• NSAIDs may be used short-term for pain from other conditions 1
• Mild arthritis may respond to NSAIDs alone 1

Monitoring Schedule

Follow patients every 4-8 weeks in year 1, every 8-12 weeks in year 2, and as needed thereafter. 1

At Each Visit Document:

• Disease activity and pain scores 1
• ESR and CRP 1
• Evidence of glucocorticoid side effects 1
• Comorbidity status 1

Expected Treatment Duration:

• Typically 2-3 years, but may be longer 4
• Some patients require <1 year if low baseline ESR and rapid response 6

Common Pitfalls

Beware of partial responders: Patients with persistently elevated IL-6 despite ESR improvement and higher baseline pain scores may require longer treatment duration and higher cumulative glucocorticoid doses. 6

Screen for giant cell arteritis: Approximately 20% of PMR patients develop GCA, and up to two-thirds of GCA patients have PMR symptoms—maintain high vigilance for new headache, jaw claudication, or visual symptoms. 4

Ensure rapid access to care: Patients need direct access to healthcare providers to report flares and adverse events promptly. 1