Polymyalgia Rheumatica

Polymyalgia rheumatica is characterized by bilateral proximal aching of the shoulder and hip girdle muscles and the back (upper and lower) and neck muscles. Stiffness in the morning is typical and lasts > 60 minutes. Shoulder symptoms reflect proximal bursitis (eg, subdeltoid, subacromial) and less often bicipital tenosynovitis or joint synovitis. Discomfort may awaken patients from sleep and is worse in the morning; occasionally it is severe enough to prevent patients from getting out of bed and from doing simple activities. The pain may make patients feel weak, but objective muscle weakness is not a feature of the disorder.

Polymyalgia rheumatica is suspected in older patients with typical symptoms, but other possible causes must be excluded.

Tests include erythrocyte sedimentation rate (ESR), C-reactive protein, complete blood count, thyroid-stimulating hormone levels, and CK. In > 80% of patients, ESR is markedly elevated, often > 100 mm/hour, usually > 50 mm/hour (Westergren method). C-reactive protein is also elevated. Electromyography, biopsy, and other tests (eg, rheumatoid factor), which are normal in polymyalgia rheumatica, are sometimes done to rule out other clinically suspected diagnoses.

The following findings in polymyalgia rheumatica distinguish it from

Prednisone started at 15 to 20 mg orally once a day results in dramatic improvement, often very rapid (in hours or days), and this response can help support the diagnosis. If giant cell arteritis is suspected, the dose of corticosteroids should be higher, and diagnostic evaluation for giant cell arteritis Diagnosis Giant cell arteritis involves predominantly the thoracic aorta, large arteries emerging from the aorta in the neck, and extracranial branches of the carotid arteries. Symptoms of polymyalgia... read more should be done.

Treatment effectiveness is monitored by symptoms, ESR, and C-reactive protein. As symptoms subside, corticosteroids are tapered to the lowest clinically effective dose, regardless of ESR. C-reactive protein is more helpful than ESR in guiding response to treatment because ESR may be persistently elevated in older patients because of other reasons. Some patients are able to stop corticosteroids in about 2 years, even sooner without relapse, whereas others require small doses for years. Nonsteroidal anti-inflammatory drugs (NSAIDs) are rarely sufficient.

Some patients who are unable to have their prednisone dose tapered and who have frequent recurrences may benefit from the addition of methotrexate (10 to 15 mg orally once a week), if renal function is normal. Adding a second drug in polymyalgia rheumatica is controversial because controlled randomized trials have shown minimal or no benefit. Trials using anti-tumor necrosis factor (TNF) drugs (infliximab and adalimumab) and rituximab have not shown benefit.

In older patients, physicians should watch for and treat complications of corticosteroid use (eg, diabetes, hypertension). Patients taking prednisone long term should be given a bisphosphonate to prevent osteoporosis.

Giant cell arteritis Giant Cell Arteritis Giant cell arteritis involves predominantly the thoracic aorta, large arteries emerging from the aorta in the neck, and extracranial branches of the carotid arteries. Symptoms of polymyalgia... read more may develop at the onset of polymyalgia rheumatica or much later, sometimes even after patients appear cured of the disorder. Therefore, all patients should be instructed to immediately report headache, muscle pain during chewing, and, particularly, visual disturbances to their physician.