Polymyalgia rheumatica
Polymyalgia rheumatica (PMR) is an inflammatory disorder of older adults causing aching and prolonged morning stiffness of the shoulder and hip girdles with elevated inflammatory markers, but without true weakness and with a normal creatine kinase. It is a clinical diagnosis, and treatment begins with prednisone 12.5 to 25 mg/day, which produces a dramatic response within days.
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What this article covers
- Overview
Definition and cardinal presentation: polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder of older adults causing bilateral, symmetric aching and prolonged morning stiffness of the…
- Epidemiology
Age-restricted disease: onset is almost exclusive to patients older than 50, with a mean age at diagnosis of about 73 years; women are affected more often than men, and PMR is most common in persons of Northern European descent.
- Risk factors
Age over 50 years: the dominant risk factor; PMR does not occur in younger adults.
- Pathophysiology
Cytokine-driven periarticular inflammation: girdle pain and stiffness reflect inflammation of the bursae, tendon sheaths, and synovium of the shoulders and hips (subdeltoid bursitis, biceps…
- Clinical features
Bilateral shoulder girdle aching and stiffness: present in nearly all patients, often extending to the hip girdle and neck, symmetric, with difficulty rising from a chair, dressing, or reaching overhead.
- Differential diagnosis
Giant cell arteritis: shares girdle aching, but adds cranial ischemic features, temporal artery tenderness, and jaw claudication; up to 20% of PMR patients have or develop it and need urgent…
- Diagnosis
First, establish that this is a clinical diagnosis: made from the symptom pattern in a patient older than 50, supported by an elevated ESR and/or CRP and, retrospectively, by a dramatic steroid…
- Management
First-line, all patients: start prednisone 12.5 to 25 mg PO once daily.
- Complications
Progression to or unmasking of GCA: 10% to 20% of PMR patients have or develop it, risking irreversible vision loss from ischemic optic neuropathy if unrecognized (giant cell (temporal) arteritis).
- Prognosis
Generally favorable with treatment: most patients achieve good symptomatic control on prednisone, though periodic recurrences during the taper are common.
- Prevention
Bone protection at treatment initiation: obtain baseline bone densitometry, and start calcium 1200-1500 mg/day plus vitamin D (600-800 IU/day, or repletion if 25-hydroxyvitamin D is under 20 ng/mL)…
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