Polymyalgia

Polymyalgia Rheumatica (PMR): Comprehensive Guide for Healthcare Professionals and Patients

1. Introduction

  • Definition: Polymyalgia rheumatica (PMR) is an inflammatory condition characterized by pain and stiffness in the shoulders, neck, and hips, primarily affecting individuals over 50 years old.
  • Epidemiology: PMR predominantly affects women and is more common in individuals of Northern European descent, with a peak incidence between 70–80 years of age.
  • Significance: PMR can significantly impair daily activities and is closely associated with giant cell arteritis (GCA), a more serious inflammatory condition requiring immediate attention.

2. Causes and Risk Factors

  • Causes:
    • The exact cause is unknown, but immune system dysfunction and genetic predisposition are suspected.
    • Possible triggers include infections or environmental factors.
  • Risk Factors:
    • Age >50 years.
    • Female gender (2–3 times more common in women).
    • Genetic predisposition (e.g., HLA-DR4).

3. Pathophysiology

  • Chronic inflammation involving cytokines (IL-6, IL-1, TNF-alpha) leads to synovitis and bursitis in proximal joints, resulting in pain and stiffness.

4. Symptoms and Features

  • Common Symptoms:
    • Bilateral shoulder and hip pain, often worse in the morning.
    • Morning stiffness lasting >30 minutes.
    • Fatigue, low-grade fever, and unintentional weight loss.
  • Associated Features:
    • Difficulty with activities like dressing or rising from a chair.

5. Complications

  • Functional disability due to persistent pain and stiffness.
  • Risk of developing giant cell arteritis (15–20% of cases).
  • Corticosteroid-related side effects from long-term treatment.

6. Diagnosis

  • Clinical Features: Symmetrical pain and stiffness in proximal muscles, with symptom onset lasting at least 2 weeks.
  • Laboratory Tests:
    • Elevated inflammatory markers: ESR (>40 mm/hr), CRP.
    • Normal muscle enzymes (e.g., creatine kinase) to rule out myopathies.
  • Imaging:
    • Ultrasound or MRI: Evidence of synovitis or bursitis.

7. Management Overview

  • Goals: Rapid symptom relief and prevention of complications.
  • Approach: Corticosteroids as the mainstay of treatment, with adjunctive therapies for long-term management.

8. Treatment Options with Cost (USD)

  • Corticosteroids: Prednisone (~$10–$30/month depending on dosage).
  • Adjunctive Therapy:
    • Methotrexate (~$30–$60/month) for steroid-sparing effect.
    • NSAIDs (~$5–$20/pack) for mild symptom relief.
  • Vitamin D and Calcium: ~$10–$25/month for bone health.

9. Advanced Treatment Options with Cost (USD)

  • Biologics (e.g., Tocilizumab): ~$3,000–$5,000/month for refractory cases.
  • Intravenous Corticosteroids: ~$100–$300 per infusion for severe flare-ups or associated GCA.

10. Pharmacological Treatment

  • First-line: Prednisone (15–20 mg/day initially, tapered gradually over 1–2 years).
  • Adjunctive Therapy: Methotrexate for patients requiring long-term steroids.
  • Supportive: Calcium and vitamin D supplements to prevent osteoporosis.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
PrednisoneFirst-line therapy15–20 mg/day initiallyWeight gain, hyperglycemia, osteoporosis
MethotrexateSteroid-sparing agent10–25 mg weeklyNausea, fatigue, liver toxicity
TocilizumabRefractory PMR162 mg subcutaneously weeklyRisk of infection, liver toxicity
Calcium/Vitamin DBone health maintenance1,200 mg/day (calcium); 800–1,000 IU/day (vitamin D)GI upset (calcium), hypercalcemia
NSAIDsSymptom reliefIbuprofen 400–600 mg every 6–8 hoursGI upset, cardiovascular risks

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
PrednisoneDeltasone$10–$30 per month
MethotrexateRheumatrex, Trexall$30–$60 per month
TocilizumabActemra$3,000–$5,000 per month
Calcium/Vitamin DCaltrate, Citracal$10–$25 per month
IbuprofenAdvil, Motrin$5–$20 per pack

12. Lifestyle Interventions

  • Regular low-impact exercise (e.g., walking, swimming) to improve mobility and reduce stiffness.
  • Balanced diet rich in calcium and vitamin D to support bone health.
  • Smoking cessation and limiting alcohol consumption.

13. Monitoring Parameters

  • Regular assessment of ESR/CRP to monitor inflammation.
  • Monitoring for corticosteroid side effects (e.g., blood glucose, bone density).
  • Regular clinical evaluation for symptoms of giant cell arteritis.

14. Patient Counseling Points

  • Importance of adherence to steroid tapering schedules to prevent relapse.
  • Recognizing symptoms of GCA (e.g., new-onset headache, vision changes) and seeking immediate care.
  • Discuss the potential side effects of long-term steroid use and ways to mitigate risks.
  • Encourage regular follow-up and lifestyle modifications to manage symptoms.

15. Special Populations

  • In Children: PMR does not typically occur in children.
  • In Pregnancy: Prednisone is generally safe; ensure adequate calcium and vitamin D supplementation.
  • In Elderly: Increased risk of corticosteroid-related side effects; require close monitoring.

16. Prevention

  • No definitive prevention; early recognition and treatment are key to reducing complications.
  • Maintain bone health through diet, exercise, and supplements.

17. FAQs

  1. What is polymyalgia rheumatica?
    Answer: An inflammatory condition causing pain and stiffness in the shoulders and hips.
  2. What causes PMR?
    Answer: The exact cause is unknown, but it is linked to immune dysfunction.
  3. Who is at risk for PMR?
    Answer: Individuals over 50, especially women and those of Northern European descent.
  4. What are the symptoms?
    Answer: Morning stiffness, bilateral shoulder and hip pain, and fatigue.
  5. How is PMR diagnosed?
    Answer: Based on symptoms, elevated inflammatory markers, and ruling out other conditions.
  6. Can PMR resolve on its own?
    Answer: PMR requires treatment; symptoms rarely resolve spontaneously.
  7. What is the treatment for PMR?
    Answer: Corticosteroids are the main treatment, often supplemented by methotrexate.
  8. Can PMR recur?
    Answer: Yes, relapse is common, especially during steroid tapering.
  9. Is PMR related to arthritis?
    Answer: PMR is an inflammatory condition but not a type of arthritis.
  10. What is giant cell arteritis?
    Answer: A serious inflammatory condition often associated with PMR, affecting large arteries.
  11. Are there long-term complications of PMR?
    Answer: Untreated PMR can cause disability; steroids may lead to side effects.
  12. How long does PMR last?
    Answer: Typically 1–2 years, though some cases persist longer.
  13. Can diet help manage PMR?
    Answer: Yes, an anti-inflammatory diet and adequate calcium/vitamin D can help.
  14. What are the side effects of prednisone?
    Answer: Weight gain, osteoporosis, high blood pressure, and diabetes.
  15. Can PMR lead to permanent damage?
    Answer: No, PMR itself does not cause permanent damage if treated early.