History
- Gradual onset of pain and stiffness affecting the shoulder and pelvic girdle.
- Age >50
- Malaise, fever weight loss.
Examination
- Unremarkable
Investigations
- Routine bloods- FBC, U&E, LFT – typically normal
- C-reactive protein and ESR – almost always elevated.
- X-rays and other imaging – unhelpful
M.A & S.R/H.B. 25-01-24
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.
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
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)
