• Clinical science

Polymyalgia rheumatica

Summary

Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disease that mainly affects patients above the age of 50 years and occurs twice as often in women than in men. Patients typically present with new-onset pain in their shoulders, hips, or neck, morning stiffness, and systemic symptoms (e.g., fatigue, malaise, B symptoms, and depressed mood). In addition to clinical presentation, the diagnosis is made based on laboratory studies, which usually show a highly elevated erythrocyte sedimentation rate (ESR), while creatine kinase and autoantibodies are negative. Bursitis and serositis in the joints of the shoulder and pelvic girdle on ultrasound may also help to confirm the diagnosis. The most important step in the management of PMR is to administer a low dose of oral glucocorticoids and taper them slowly until full remission is achieved. Patients with polymyalgia rheumatica should be routinely monitored for symptoms of giant cell arteritis because this type of vasculitis commonly develops during the course of the disease.

Epidemiology

  • Sex: > (3:1) [1]
  • Most common inflammatory rheumatic disease in the elderly (second most common overall)
  • Age of onset: >70 years (rarely seen in patients < 50 years) [2]
  • More common in individuals of Northern European descent [3]

Women of advanced age are particularly prone to the disease.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Clinical features

  • Systemic symptoms
  • Musculoskeletal symptoms: primarily affects shoulders, neck, and pelvic girdle
    • New onset, symmetric pain that is worse at night
    • Morning stiffness (> 45 min)
    • Muscular atrophy and weakness: not directly caused by PMR but resulting from reduced activity due to pain and stiffness [5]
  • Other: symptoms of giant cell arteritis (if both diseases are present)

Diagnostics

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

  • Low-dose oral glucocorticoids (alternatively IM glucocorticoids) [8]
    • Usually rapid response (2–4 weeks)
    • If symptoms improve: slowly taper and eventually stop glucocorticoids
    • No improvement after 2 weeks or relapse: increase dose
  • 1. Crowson CS, Matteson EL, Myasoedova E, et al. The lifetime risk of adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases. Arthritis Rheum. 2011; 63(3): pp. 633–639. pmid: 21360492.
  • 2. Michet CJ, Matteson EL. Polymyalgia rheumatica. BMJ. 2008; 336(7647): pp. 765–9. doi: 10.1136/bmj.39514.653588.80.
  • 3. Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, et al. Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009; 61(10): pp. 1454–61. doi: 10.1002/art.24459.
  • 4. Unwin B, Williams CM, Gilliland W. Polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2006; 74(9): pp. 1547–54. pmid: 17111894.
  • 5. Harvard Health Publishing. Polymyalgia rheumatica. https://www.health.harvard.edu/diseases-and-conditions/polymyalgia-rheumatica. Updated November 1, 2011. Accessed April 11, 2020.
  • 6. Ameer F, McNeil J. Polymyalgia rheumatica: clinical update. Aust Fam Physician. 2014; 43(6): pp. 373–6. pmid: 24897986.
  • 7. Kermani TA, Warrington KJ. Advances and challenges in the diagnosis and treatment of polymyalgia rheumatica. Ther Adv Musculoskelet Dis. 2013; 6(1): pp. 8–19. doi: 10.1177/1759720x13512450.
  • 8. Dejaco C, Singh YP, Perel P, et al. Recommendations for the management of polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum. 2015; 67(10): pp. 2569–2580. doi: 10.1002/art.39333.
last updated 10/22/2020
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