Polymyalgia Rheumatica (PMR)

Last updated 30.03.13

 

Index

 

Definition

-  Common autoimmune inflammatory polyarthropathy

 

Features

-  Avg age of onset 70yrs old

-  Rare <55yrs old

-  Women > men

-  Low grade synovitis

-  Rapid response to corticosteroids

-  Idiopathic

 

Associated S/S

-  Symetrical aching & stiffness of shoulders, neck, hip girdle

-  Worse after inactivity & at night

-  Difficulty in turning over in bed & getting out of bed in morning

-  Improves after hot shower & activity

-  Sudden or gradual onset

-  Morning stiffnes >30min

-  +/- painful restriction of active & passive movements

-  Fatigue

-  Low grade fever

-  Anorexia

-  Temporal arteritis

-  15% patients

-  More commonly associated as age increases

 

Dx Criteria (British)

-  Bialteral shoulder or pelvic girdle aching (or both)

-  Morning stiffness >45 min

-  >50yrs old

-  Duration >2 weeks

-  Elevated ESR &/or CRP

 

DDx

-  Rotator cuff injury

-  Supraspinatus tear

-  Fibromyalgia

-  Polymyositis

-  Statin myalgia

-  Hypothyroidism

-  Cancer

-  Myelodysplasia

-  Lymphoma

-  Leukaemia

-  Rheumatoid Arthritis

 

Ix

-  ESR

-  Unlikely if normal

-  If clinically suspected repeat ESR & CRP in 1-2 weeks

-  CRP

-  More sensitive indicactor of disease activity

-  +/- Temporal artery Bx: Temporal arteritis

-  +/- BMD

-  Ix to exclude related conditions

-  RF, HLA-B27

-  +/- ANA, Anticyclic citrullinated peptide antibodies

-  TFT

-  FBE, U&E, CK, LFT, CMP

-  Protein electrophoresis

-  +/- Bence Jones proteins

 

Mx

-  Low impact exercise: swimming, walking

-  Corticosteroids

-  Lowest possible dose for shortest possible duration

-  Monitor for loss of bone density & cushings syndrone

-  In absence of Temporal arteritis

-  Prednisolone 10-20mg PO Mane for 2-4 weeks

-  If ESR, CRP normal reduce dose by 2.5mg every 2-4 weeks until 10mg

-  Then decreased dose by 1mg every 4-8 weeks

-  Treatment usually requires 2-3yrs+

-  Consider IM Methylprednisolone 120mg every 3-4 weeks reducing by 20mg every 2-3 months

-  Vitamin D & Calcium

-  To reduce bone effects of steroid therapy

-  Consider Bisphosphanate is high risk of known low BMD

-  Ongoing R/V

-  Repeat ESR/CRP + FBE, U&E, BSL at 4 weeks

-  Consider repeating each 4 weeks

-  If not prompt improvement (2weeks max) in S/S &/or ESR, CRP consider alternative Dx

-  >70% pts show significant improvement within 1/52

-  Corticosteroids dosing based on relapse

-  Monitor for Temporal arteritis

-  Referral

-  Atypical features

-  No shoulder involvement

-  Weight loss, night pain, neuro defecit

-  Contraindications to steroid therapy

-  If requiring high dose steroids over long duration refer to specialist +/- for Methotrexate

 

 

 

References

 

eTG: Polymyalgia Rheumatica, 2013

AFP: Polymyalgia Rheumatics: Diagnosis & Management, Vol 40, May 2011