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Polymyalgia RheumaticaAka: PMR

See Also
1. Temporal Arteritis
Epidemiology
1. Common over age 50 years
  1. Incidence: 50 per 100,000
2. Rare in Asian and black patients
3. Women predominate by 2:1 ratio
4. Associated with HLA-DR4 and Cw3 haplotypes
5. Associated with Temporal Arteritis (15%)
Symptoms
1. Severe muscle ache and stiffness
  1. Duration: 1 month or longer at presentation
    1. Usually insidious onset
  2. Location (symmetric involvement)
    1. Shoulders (most commonly affected)
    2. Neck
    3. Pelvic girdle and hips
  3. Characteristics
    1. Ache and stiffness
  4. Timing
    1. More prominent in morning or after inactivity
2. Associated systemic symptoms
  1. Malaise
  2. Anorexia
  3. Weight loss
  4. Low grade fever
  5. Depressed mood
  6. Night Sweats
Signs
1. Unremarkable physical exam
  1. Symptoms are usually well out-of-proportion to exam
  2. No true weakness
2. Mild findings (variably present)
  1. Limited range of motion in affected joints
    1. Limited by proximal myalgias
  2. Shoulder or hip bursitis
  3. Localized tenderness over shoulders and hips
3. Other findings which may be present
  1. Asymmetric knee or wrist arthritis
  2. Carpal Tunnel Syndrome
  3. Distal extremity edema
Diagnosis of Exclusion; Need Absence of
1. Inflammatory arthritis
2. Infection
3. Malignancy
4. Hypothyroidism
Labs
1. Erythrocyte Sedimentation Rate
  1. Increased > 50 mm in 1 hour (often >100 mm)
2. Creatine Phosphokinase (CPK) Normal
  1. Differentiate from Polymyositis
3. Nonspecific Lab findings
  1. Moderate Anemia
  2. Decreased Serum Albumin
  3. Mild hepatic dysfunction
Associated Conditions: Temporal Arteritis
1. Occurs in 15% of PMR patients
2. Risk of blindness
3. Consider Temporal Arteritis in all PMR patients
4. Factors suggesting concurrent Temporal Arteritis
  1. Age over 70 years
  2. New onset Headache
  3. Jaw Claudication
  4. Raised liver enzymes
  5. Abnormal temporal arteries on exam
5. References
  1. Rodriguez-Valverde (1997) Am J Med 102:331
Management
1. General measures
  1. Consider concurrent Temporal Arteritis (See above)
  2. NSAIDs
2. Prednisone (key to management)
  1. See Corticosteroid Associated Osteoporosis
  2. Efficacy: 90% response
    1. Dramatic improvement in first 48 hours
    2. If no response to steroids
      1. Reconsider diagnosis
      2. Consider Methotrexate
  3. Polymyalgia alone
    1. Dose: 15-20 mg PO qd
  4. Polymyalgia with Temporal Arteritis
    1. Dose: 40-60 mg PO qd
    2. Symptoms and signs remit within 1 month
    3. Decrease dose by 10% each week after improvement
  5. Course
    1. Initial: Maintain starting dose for 1 month
    2. First steroid taper (depends on clinical response)
      1. Taper by 2.5 mg per month down to 10 mg/day then
      2. Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day
    3. Final steroid taper
      1. Indicated when symptom free for 6-12 months
      2. Do not taper until sedimentation rate normalizes
      3. Taper by 1 mg every 6-8 weeks until done
    4. Anticipate 2-6 year course of steroids
      1. Relapse common in first 18 months of steroid use
      2. Patients off steroids at 2 years: 25%
  6. Prevention of Corticosteroid related Osteoporosis
    1. See Corticosteroid Associated Osteoporosis
Prognosis
1. Self limited course over years (usually 3-6 years)
References

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This page was written by Scott Moses, MD, and was last revised 1/27/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 5.0.