Polymyalgia Rheumatica by drdoc on-line

This is an illness that we quite commonly see as Rheumatologists.

It is often seen in articles in the lay press and several of my new patients have come into my rooms having read about it - and asking if this is the problem they have.

It is characterized by stiffness and aching in the musculoskeletal system, especially at the shoulder girdle and the pelvic and limb girdles. The symptoms are worse in the morning and patients may complain of difficulty getting out of bed and difficulty lifting their arms above their heads. There may be a fever and loss of weight as well.

The condition usually arises over the age of 50-60 years and is twice as common in females as men. The annual incidence is approximately 50 / 100000 people per year and the prevalence is approximately 33 / 1000 0f the population above age 65.

The cause is unknown, but there seems to be a genetic background and an immune mechanism.
The condition has some relationship to Giant cell arteritis - also known as temporal arteritis.

Physical examination often reveals very little -
The most common findings are soft tissue in character...

For example:
Rotator cuff /subachromial bursitis / shoulder tendonitis Trochanteric Bursitis.
Vague tenderness of the proximal muscles of the thighs and upper limbs.

An arthritis may sometimes be seen - in approximately 50 % of cases - usually a mild synovitis However an erosive arthritis has been demonstrated to occur in some case reports and variably up to 4% of cases.

Unlike Temporal arteritis there is no definite confirmed association with underlying cancers.

Blood tests :

The ESR and CRP are classically elevated - although a small percentage of patients may have a normal test.
There may be a mild anemia.
The rheumatoid factor is not elevated - but remember - the condition is seen in the elderly and a false positive elevation of the Rheumatoid factor may be seen anyway.

Treatment :

Classically the condition is very responsive to steroid therapy, given as oral tablets - i.e. prednisone.
My method is to start at a lower dose than classically described ( 20mg)

The usual recommended starting dose is 20mg.
However -  I use much smaller doses - 7.5mg and only go up to 10 mg or higher if there is no response.
I usually find 7.5 mg is enough.

It is very rare to require higher doses.

The results are usually dramatic.
Then starts the difficult part...the weaning of the dose.

Steroids ie cortisone have many side effects. These include:

Skin thinning and bruising
Weight gain
High blood pressure

Hence we use as small a dose as possible to get the positive effect.

Most patients stay at 7.5mg for 4 - 6 weeks and then I try to go down to
5 mg for 3 months - 3 - 6 months  ... then down to ...
2.5mg for 3 - 6 months and then ...
2.5mg alternate day for 3 - 6 months.. then ...
2.5mg every third day for 3 - 6 months and hopefully we can stop.
Most people stop by 12 months.

Some patients require a small maintenance dose of 2.5mg daily or alt day or every third day ongoing. However I am not personally anxious about this as the side effect profile at these doses are very small.

A nocturnal anti-inflammatory may be useful in some patients.

Physical therapy may be useful.

Diet - I suggest a low fat / red meat diet and lots of fish and vegetables.

Exercise - In active phase - rest is important. However once the stiffness starts to subside - I start to mobilise the patients with hydrotherapy if possible and then walking progressively more each week.

Persistence of the CRP may require a search for additional pathology.

A increase in peripheral joint swelling also may require a review of diagnosis especially sero negative rheumatoid arthritis

There are a few patients who may develop Giant cell arteritis with the development of temporal distribution headaches - and your doctors should be aware of this potential - as the therapy for the latter is more aggressive.
However most people do well and the condition is self limiting in the majority.


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