1. Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines
HDR Wednesday 23rd November 2011
By Dr Mahya Mirfattahi GP Registrar

2. Core inclusion criteria
Age >50 years, duration >2 weeks
Bilateral shoulder or pelvic girdle aching, or both
Morning stiffness duration of >45mins
Evidence of an acute-phase response

3. PMR Can be diagnosed with normal inflammatory markers, if
classical clinical picture
Response to steroids
Should be referred for specialist assessment

4. Core exclusion criteria
Active infection
Active cancer
Active GCA
Presence of following decreases probability of PMR, therefore should be excluded
Other inflammatory rheumatic conditions
Drug-induced myalgia
Chronic pain syndromes
Endocrine disease
Neurological conditions e.g. Parkinsons disease

5. Assess for evidence of GCA
Abrupt-headache (temporal) and usually with temporal tenderness
Visual disturbance, including diplopia
Jaw or tongue claudication
Prominence, beading or diminished pulse on examination of temporal artery
Upper cranial nerve palsies
Limb claudication or other evidence of large-vessel involvement

6. Recommended baseline investigations
FBC
ESR/CRP
U&E, LFT, Calcium, CK, TSH
Protein electrophoresis & BJP
RF (ANA & anti-CCP may be considered)
Dipstick urine
CXR

7. Early specialist referral
Age <60 years
Chronic onset >2 months
Lack of shoulder involvement
Lack of inflammatory stiffness
Prominent systemic features weight loss, night pain, neurological signs
Features of other rheumatic disease
Normal of extremely high acute-phase response
Management dilemmas
Poor response to treatment, needing treatment >2 years, relapses, corticosteroid contraindicated or not tolerated

8. Treatment Low-dose steroid Suggested regimen
Daily prednisolone 15mg for 3 weeks
Then 12.5mg for 3 weeks
Then 10mg for 4-6 weeks
Then reduce by 1mg every 4-8 weeks
Alternative is methylprednisolone
Milder cases or steroid-related complications
Initial dose 120mg every 3-4 weeks, reducing by 20mg every 2-3 months
Usually 1-2 years of treatment needed
If >2 years refer

9. Recommended use of bone protection
Individual with high fracture risk e.g. aged >65 years or prior fragility fracture
Bisphosphonate with calcium and vitamin D
DEXA not needed
Other individuals
Calcium and vitamin D supplementation when starting steroid therapy
DEXA scan recommended
A bone-sparing agent if T-score <-1.5

10. Monitoring Follow up schedule At each visit assess
Weeks 0,1-3, 6
Months 3,6,9, 12 in first year
At each visit assess
Response to treatment: proximal pain, fatigue and morning stiffness
Complications of disease including symptoms of GCA
Steroid-related adverse effects
Atypical features or those suggesting an alternative diagnosis
FBC, ESR/CRP, U&E, glucose
Usually 1-3 years of treatment

11. Relapses Not just rise in ESR/CRP
Clinical features of GCA: treat as GCA (40-60mg prednisolone & urgent referral)
Clinicial features of PMR: increase prednisolone to previous higher dose
Single IM injection of methylprednisolone can also be used
Further relapses: DMARD after 2 relapses