What is the appropriate diagnosis and treatment approach for an older adult patient with elevated protein and albumin levels, suspected to have Polymyalgia Rheumatica (PMR)?

Elevated Protein with PMR: Diagnostic Interpretation and Management

The elevated total protein (8.4 g/dL) with normal albumin (3.6 g/dL) suggests a polyclonal gammopathy pattern that warrants protein electrophoresis to exclude paraproteinemia, which can mimic PMR symptoms, while proceeding with standard PMR diagnostic workup and treatment if clinical features are consistent. 1

Understanding Your Laboratory Findings

The gap between total protein and albumin indicates elevated globulins, which can occur in:

• Chronic inflammation from PMR itself - The inflammatory response in PMR drives immunoglobulin production, commonly causing mild polyclonal hypergammaglobulinemia 1
• Paraproteinemia or multiple myeloma - These conditions can present with PMR-like symptoms and must be excluded, particularly in older adults 1

Essential Diagnostic Workup

Core inflammatory markers:

• Measure ESR and/or CRP immediately - these are elevated in >90% of PMR cases and are essential for diagnosis 1, 2
• High ESR (>40 mm/1st hour) indicates more aggressive disease with higher relapse risk 1, 3

Mandatory exclusionary testing:

• Protein electrophoresis is specifically recommended to exclude paraproteinemia given your elevated total protein 1
• Rheumatoid factor and/or anti-CCP antibodies to exclude rheumatoid arthritis 1
• Complete blood count to assess for anemia of inflammation 1
• Creatine kinase must be normal in PMR (differentiates from inflammatory myositis) 1

Pre-treatment baseline labs:

• Glucose, creatinine, liver function tests 4, 1
• Bone profile (calcium, alkaline phosphatase) 4, 1
• TSH to exclude thyroid disorders 1
• Vitamin D level 1
• Urinalysis 1

Extended testing if atypical features present:

• ANA and ANCA if other autoimmune conditions suspected 1
• Chest radiograph to exclude malignancy 1

Clinical Diagnostic Criteria

PMR diagnosis requires:

• Age >50 years (typically ~73 years at onset) 5
• Bilateral shoulder pain with subdeltoid bursitis 2
• Morning stiffness and functional impairment 2
• Elevated inflammatory markers (ESR/CRP) in >90% 2, 5
• Dramatic response to low-dose glucocorticoids within days 1

Treatment Algorithm

Initial glucocorticoid therapy:

• Start prednisone 12.5-25 mg daily - this is the strongly recommended range 4, 1, 6, 7
• Use higher doses (20-25 mg) if high ESR (>40), female sex, or peripheral arthritis present (relapse risk factors) 4, 6
• Use lower doses (12.5-15 mg) to minimize cumulative glucocorticoid exposure and adverse effects 8

Tapering strategy:

• Reduce slowly at <1 mg/month once below 10 mg/day - this reduces relapse rates compared to faster tapering 8
• Starting doses >15 mg/day are associated with more glucocorticoid-related adverse effects 8
• Treatment duration typically 2-3 years but may be longer 5

Monitoring Schedule

First year:

• Follow-up every 4-8 weeks 4, 3
• Monitor ESR/CRP, glucose, blood count at each visit 3
• Assess for glucocorticoid side effects continuously 4

Second year:

• Follow-up every 8-12 weeks 4, 3
• Increase frequency if flare suspected 3

Critical Pitfalls to Avoid

• Do not miss paraproteinemia - your elevated protein mandates electrophoresis before attributing it solely to PMR inflammation 1
• Do not start with NSAIDs - glucocorticoids are strongly recommended as first-line, not NSAIDs 4
• Do not use starting doses >15 mg if avoidable - higher doses increase adverse effects without proportional benefit 8
• Do not taper faster than 1 mg/month below 10 mg/day - this increases relapse risk 8

When to Refer to Rheumatology

Consider specialist referral for: 4, 6

• Age <60 years
• Peripheral inflammatory arthritis
• Low or normal inflammatory markers despite symptoms
• Systemic symptoms beyond typical PMR
• Refractory disease or frequent relapses
• High risk for glucocorticoid complications

Special Considerations for Your Case

Female patients have:

• Higher risk of glucocorticoid side effects 4, 6
• Higher relapse rates requiring prolonged therapy 4, 3, 6
• Need for more vigilant monitoring 3

Comorbidity assessment before starting glucocorticoids: 4, 6

• Screen for hypertension, diabetes, cardiovascular disease
• Assess for osteoporosis risk (particularly recent fractures)
• Evaluate for peptic ulcer disease, glaucoma, cataracts
• Document baseline for all conditions that glucocorticoids may worsen