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Polymyalgia Rheumatica
Rheumatoid Arthritis
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Polymyalgia Rheumatica
Last updated 8th March 2024
Diagnosis
- Based on evaluation of core inclusion and exclusion criteria followed by assessment of response to steroid which is usually dramatic when PMR is present
Core Inclusion Criteria
- Bilateral shoulder and/or pelvic girdle pain and stiffness
- Morning stiffness >45 minutes
- Age at disease onset >50 years
- Duration >2 weeks
- Acute phase response ESR/CRP
Core Exclusion Criteria
- Active cancer
- Active Infection
- Active GCA – and must always assess for this
- Other inflammatory rheumatic diseases eg RA
- Other pain syndromes eg fibromyalgia, or drug-induced myalgia
- Endocrine disease eg new Hypothyroid
- Neurological disease eg Parkinsons
Necessary Pre-Treatment Tests
- FBC, ESR/CRP, U+E, LFT, Bone profile, serum electrophersis, TSH, CK, Rheumatoid Factor, Dipstick Urinalysis, possibly CXR
Management of PMR
- Prednisolone at 15mg od for 3 weeks
- Then 12.5mg for 3 weeks
- Then 10mg for 4-6 weeks
- Then reduction by 1mg every 4-8 weeks
- Unlike GCA, urgent therapy with steroid is not necessary and can be delayed to allow full assessment
- A patient reporting global improvement of ≥70% within a week of starting steroids and normalisation of inflammatory markers within 4 weeks is consistent with PMR, otherwise refer
- If steroid dose remains unacceptably high (>15mg by 3 months) , or 2 relapses, consider steroid sparing agents or intramuscular steroids
- Rx bone and gastroprotection as indicated
- Refer Rheumatology if <60 years, chronic onset>2/12, lack of shoulder involvement, prominent systemic features- sweats, weight loss, night pain ex=tc, other Rheumatic disease , or normal or very high ESR/CRP
Follow Up
- Within 1-3 weeks then according to need supported by ESR/CRP, assess for GCA or Rx complications.
- 50% patients should be able to stop steroid by 2 years and 50% of the remainder by 4 years
- Isolated raised ESR is not an indication for continuing or increasing steroid therapy but may require investigation and referral in its own right. Persistent Pain may arise from OA, Rotator cuff dysfunction
- Incomplete, poorly sustained or non response to steroid should prompt a search for an alternative diagnosis and referral to rheumatology clinic as should the need for therapy after 4 years
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Content updated by Lucy Moran