Polymyalgia Rheumatica

When to refer:

• Patient fails to respond adequately to corticosteroid therapy (suggests the diagnosis is incorrect).

Symptoms cannot be controlled with less than 10mg prednisolone daily (for consideration of immunosuppressives)

When not to refer:

• Uncomplicated Polymyalgia Rheumatica can be managed in general practice.

How to refer:

SCI Gateway > Rheumatology > WGH

Management of Polymyalgia Rheumatica

In a patient with characteristic symptoms, raised inflammatory markers and no alternative diagnosis such as infection or cancer, do the following:

• Check: FBC, U&E, LFT, CRP, ESR and HbA1c before starting steroids
• Warn patient about symptoms of hyperglycaemia.
• Issue steroid card and advise patient about steroid sick day rules (please refer to Endocrinology Refhelp page – see further information)
• If HbA1c > 42 , refer to Management of long term high dose steroid therapy – RefHelp (nhslothian.scot)
• Prescribe 15 mg prednisolone daily.
• Arrange review after 1 week, to assess symptomatic response and recheck inflammatory markers.

In Polymyalgia Rheumatica symptoms should have improved by at least ≥ 70% within a week with a drop in inflammatory markers.

If patient does not respond, consider alternative diagnosis and/or refer to rheumatology. If the patient does respond, then continue steroids dose reduction as below:

Steroid reduction in Polymyalgia Rheumatica:Prednisolone 15mg for 3-4 weeks Then reduce by 2.5mgs every 3 weeks till on 10 mg daily.Reduction by 1mg every month thereafterWhen the patient reaches a dose of 4mg daily check a morning cortisol before reducing further.  If cortisol is >425nmol/L, proceed with dose reduction and stop Prednisolone if possible. If cortisol is 275 – 425nmol/l, proceed with dose reduction with sick day dosing of 10mg prednisolone (or seek medical attention if unable to take) as per steroid emergency card for 3 months. I cortisol <275nmol/L continue prednisolone 4mg daily and  refer to Endocrinology for further advice.Typically patient may be on steroids 1-2 yearsThe dose reduction should be titrated against symptoms and ESR (do not treat the ESR in the absence of symptoms). If symptoms recur and ESR becomes elevated then increase the prednisolone dose by 5mg daily and resume dose reduction at 1mg/month.

Bone protection

Treatment should be commenced with alendronic acid 70mg once a week accompanied by cholecalciferol 800 units daily. Alternatives include Risedronate 35mg once a week or liquid buffered alendronate (Binosto, 70mg weekly). A combined calcium and vitamin D supplement (Accrete D3, 1000/880) is indicated in patients with dietary calcium intake <700mg daily. Dietary calcium intake can be calculated by completion of a simple food frequency questionnaire using a dietary calcium calculator.

All patients should be considered for vitamin D supplements (Colecalciferol 800 u daily) and calcium supplements if their dietary Calcium intake is < 700 mg/day. A DEXA scan should be considered in patients who have a 10-year risk for major osteoporotic fractures of >10 %. Oral bisphosphonate treatment should be commenced pending the results of DEXA.

Dual energy x-ray absorptiometry

It is not necessary to refer patients aged 60 years and above who are starting prednisolone for Dual Energy X-ray absorptiometry (DEXA), since there is a high likelihood they will have osteopenia and qualify for treatment. Instead, prophylactic treatment can be commenced with an oral bisphosphonate and calcium and vitamin D supplements as detailed above. Indications for DEXA in this patient group are:

• Patients under the age of 60 years
• Patients with one severe or two or more moderate vertebral fractures on X-ray (indicated if there is back pain and height loss)
• Patients who are able to come off long term prednisolone, to determine if treatment is still indicated
• Patients who have completed 5 years treatment with an oral bisphosphonate

X-rays

Thoracic and lumbar spine x-rays are indicated in patients with back pain, kyphosis or height loss to confirm of exclude the presence of vertebral fractures.

Bone protection with oral bisphosphonates should be considered in patients aged >65 that are taking >7.5mg prednisolone for >3 months. In patients < 65 DEXA is indicated to determine if bone protection is required (T-score of <-1.5 at any site is an indication for bone protection). See Corticosteroid osteoporosis pages for further information.

• Clinical guidelines for management of PMR:  https://doi.org/10.1093/rheumatology/kep303a
• Patient-centred information provided by Versus Arthritis. https://versusarthritis.org/about-arthritis/conditions/polymyalgia-rheumatica-pmr/
• Endocrinology RefHelp guidelines on management of patients on long term steroids: Management of long term high dose steroid therapy – RefHelp (nhslothian.scot)