Polymyalgia Rheumatica (PMR)

Overview

See Clinical Knowledge Summaries for advice on diagnosis and management of Polymyalgia Rheumatica (revised June 2021).

Alternatively see British Society of Rheumatology (BSR) guidelines (2009) or EULAR/ACR 2015 guidelines.

If you suspect GCA then please see the Giant Cell Arteritis page.

BSR Guidelines

Diagnosis

Core inclusion criteria:

• Age >50 years, duration >2 weeks

• Bilateral shoulder or pelvic girdle aching, or both

• Morning stiffness duration of >45 min

• Evidence of an acute-phase response

PMR can be diagnosed with normal inflammatory markers, if there is a classic clinical picture and response to steroids. These patients should be referred for specialist assessment.

Core exclusion criteria:

• Active infection

• Active cancer

• Active GCA

The presence of the following conditions decreases the probability of PMR, and they should also be excluded:

• Other inflammatory rheumatic diseases

• Drug-induced myalgia

• Chronic pain syndromes

• Endocrine disease

• Neurological conditions, e.g. Parkinson's disease.

Investigations

Arrange the following laboratory investigations before commencement of steroid therapy:

• Full blood count

• CRP and plasma viscosity

• Urea and electrolytes

• Liver function tests

• Bone profile

• Glucose/HbA1c

• Rheumatoid factor 

• Dipstick urinalysis

• Consider also checking: TSH, CK, vitamin D, ANA, anti CCP, serum protein electrophoresis and urinary free light chains

• Chest X-ray may be required

Treatment

In the absence of GCA, urgent steroid therapy is not indicated before the clinical evaluation is complete. When treatment is commenced patients should be assessed for response to an initial standardized dose of prednisolone 15 mg daily orally. A patient-reported global improvement of 70% within a week of commencing steroids is consistent with PMR, with normalization of inflammatory markers in 4 weeks.  A lesser response should prompt the search for an alternative condition.

The diagnosis of PMR should be confirmed on subsequent follow-up. Follow-up visits should include vigilance for mimicking conditions.

The suggested prednisolone weaning regimen is:

• Daily prednisolone 15mg for 3 weeks

• Then 12.5mg for 3 weeks

• Then 10mg for 4–6 weeks

• Then reduction by 1mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5mg alternate days, etc.)

However, there should be a flexible approach to this regime if needed. Usually 1–2 years of treatment is needed. 

Early follow-up is necessary as part of the diagnosis to evaluate response to initial therapy, and the first follow-up should occur at 1–3 weeks after commencement of steroids to check for

• Response to treatment: proximal pain, fatigue and morning stiffness It is important to distinguish between symptoms due to inflammation and those due to co-existing degenerative problems.
• Complications of disease including symptoms of GCA, e.g. headaches, jaw claudication and large-vessel disease
• Steroid-related adverse events
• Atypical features or those suggesting an alternative diagnosis

Laboratory monitoring:

• Full blood count, ESR/CRP, urea and electrolytes, glucose

Management of relapse:

Increase oral prednisone to the pre-relapse dose and decrease it gradually (within 4–8 weeks) to the dose at which the relapse occurred.

Determination of comorbidities:

In patients commenced on prednisolone, consider and monitor for comorbidities particularly:

• Hypertension
• Diabetes
• Glucose intolerance
• Cardiovascular disease
• Dyslipidaemia
• Peptic ulcer
• Osteoporosis (and particularly recent fractures)
• Presence of cataract or (risk factors for) glaucoma
• Presence of chronic or recurrent infections
• Co-medication with NSAIDs

Bone protection

Commence bone protective treatment at the time of prednisolone (calcium & vitamin D and alendronic acid)

Request DEXA scan to determine length of bisphosphonate treatment required.

Referral

Patients with PMR can usually be managed effectively in primary care as described above.

UHBW and NBT rheumatology teams are happy to provide advice on challenging cases via advice and guidance. Rheumatology Advice and Guidance Service

Specific PMR clinics are not available in BNSSG and referral is usually only indicated for atypical presentations, e.g.

• Age < 60 years
• Lack of shoulder involvement
• Lack of inflammatory stiffness
• Prominent systemic features, weight loss, night pain, neurological signs
• Features of other rheumatic disease e.g. peripheral inflammatory arthritis
• Normal or extremely high acute-phase response
• Refractory to steroid therapy and/or relapses/need for prolonged steroid treatment (over 2 years)

If referral is still required then please refer to Rheumatology via eRS.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.