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Polymyalgia Rheumatica (PMR)

Polymyalgia Rheumatica (PMR) is an inflammatory condition, causing pain and stiffness in the shoulders, neck, and pelvic girdle. It typically affects caucasian women > 50 yrs, and has a very strong association with Giant Cell Arteritis.


Presentation

  • Bilateral shoulder and pelvic girdle pain that’s worse with movement

  • Morning stiffness


Differentials to consider include:

  • OA, RA, SLE, Cervical spondylosis

  • Thyroid disease

  • Poly/dermatomyositis - Differentiated from a myositis, which will present with bilateral proximal muscle weakness, and no pain


N.B. Always have myopathy as a differential e.g. polymyositis, statin-induced myopathy. These will have a raised CK.

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Investigations

Main investigations to do are:

  • CRP and ESR - ESR will be very high


Other investigations include:

  • FBC, U&E, TSH

  • LFT (ALP), Bone profile - for metabolic bone disease

  • CK - for myositis

  • RF and anti-CCP - for RA

  • ANA - for SLE


Diagnosis is based on clinical presentation and the response to steroids. Symptoms have to be present for > 2 weeks for a diagnosis to be made.


Management

  • Start on Prednisolone 15mg PO

    • There should be a major improvement after 3-4 weeks - If not, PMR is unlikely, so stop steroid as an alternative diagnosis is needed

  • After good response, start on Reducing Regime

    • Stay on 15mg until full symptomatic control

  • If symptoms recur while on reducing regime, you may need to increase dose or stay on dose longer before reducing again


This weaning process can take up to 1-2 years, so patients are usually co-prescribed Bisphosphonates for bone protection.


These patients should be given a Blue Steroid Card as they’ll be on it long-term, therefore avoid medical cases where their steroids are stopped abruptly (can lead to Addisonian crisis).




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