Polymyalgia Rheumatica

September 23, 2011

Polymyalgia rheumatica (PMR) is an inflammatory condition that typically causes pain and stiffness in the neck, shoulders, and pelvic/hip muscles. It occurs almost exclusively in those over the age of 50 and occurs more often with age. Polymyalgia rheumatica usually begins with stiffness in the morning that lasts greater than 1 hr. The stiffness is usually mild in the beginning, but increases with time and may become so severe as to cause difficulty getting out of bed. Occasionally symptoms begin quite abruptly and become incapacitating almost overnight. While the neck, hips, and shoulders have the most pain and stiffness, these areas rarely have swelling. The hands, wrists, and knees are involved less often, but when they are affected, significant swelling may occur in these areas. Symptoms such as fatigue, weight loss, and less commonly fever may occur in about one third of patients. A severe headache, jaw pain, or new visual symptoms suggest the possibility of temporal arteritis, which can occur along with Polymyalgia rheumatica. This requires immediate medical evaluation, as temporal arteritis can cause sudden irreversible blindness.

The most commonly used test in the diagnosis of Polymyalgia rheumatica is the erythrocyte sedimentation rate (ESR), which indicates inflammation somewhere in the body. In Polymyalgia rheumatica, the ESR level is usually greater than 40 mm/hr. A normal ESR does not rule out the diagnosis, however, and a highly elevated ESR does not necessarily mean more severe disease. The ESR is also elevated in many conditions other than Polymyalgia rheumatica. Other laboratory abnormalities that may occur include mild anemia and occasionally abnormal tests of liver function.

Treatment with moderate doses of corticosteroids, such as prednisone 15-20 mg daily, usually leads to a prompt response with most symptoms resolving in 2-3 days. If adequate doses of corticosteroids do not improve symptoms, the diagnosis of Polymyalgia rheumatica should be reconsidered. The average length of treatment is between 1 and 4 years, with some patients requiring treatment for longer. Corticosteroids can cause multiple side effects and the minimum effective dose should be used. When the corticosteroid dose cannot be lowered to an acceptable level, addition of the drug methotrexate may help. Due to the long duration of corticosteroid therapy, treatment to prevent corticosteroid-induced osteoporosis is often given along with the corticosteroids. This may include measurement of bone density, calcium and vitamin D supplementation, and medications to treat or prevent osteoporosis.

Other inflammatory conditions such as rheumatoid arthritis, infections, and malignancy may rarely mimic Polymyalgia rheumatica. Usually, however, the diagnosis of Polymyalgia rheumatica is clear because of its characteristic symptoms, elevated ESR, and prompt response to treatment. In 10-15% of patients, however, Polymyalgia rheumatica may coexist with another condition called temporal arteritis, or giant cell arteritis. Treatment of temporal arteritis usually requires higher corticosteroid doses than Polymyalgia rheumatica. Since temporal arteritis may develop during the treatment of Polymyalgia rheumatica, symptoms of headache, jaw pain with chewing, or visual symptoms should be evaluated without delay, even in people who have responded well to treatment for Polymyalgia rheumatica.

Most people affected by Polymyalgia rheumatica will respond rapidly to treatment. With careful attention, side effects of treatment are manageable. People with Polymyalgia rheumatica are generally able to lead normal lives with minimal effect on their quality of life or functioning.

SEE ALSO: Giant cell arteritis, Osteoporosis and osteopenia, Rheumatoid arthritis

Suggested Reading

  • Hunder, G. G. (2001). Giant cell arteritis and polymyalgia rheumatica. In S. Ruddy, E. D. Harris, & C. B. Sledge (Eds.), Kelley’s textbook of rheumatology (6th ed., pp. 1155—1164). Philadelphia: W.B. Saunders.
  • Klippel, J. H. (Ed.). (2001). Primer on the rheumatic diseases (12th ed.). Atlanta, GA: Arthritis Foundation.
  • Salvarani, C., Cantini, F., Boiardi, L., & Hunder, G. (2002). Polymyalgia rheumatica and giant cell arteritis. The New England Journal of Medicine, 347, 261-271.

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