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Polymyalgia rheumatica

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Polymyalgia rheumatica



Introduction 

Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.

Morning stiffness in the muscles is the main symptom and usually lasts for about 45 minutes. It may also cause other symptoms, including:



high temperature (fever) and sweating



extreme tiredness (fatigue)



loss of appetite



weight loss



depression



If you have pain and stiffness that lasts longer than a week, you should see your GP so the cause can be investigated.

Diagnosing polymyalgia rheumatica can be difficult because the symptoms are similar to those of many other conditions, includingrheumatoid arthritis. These conditions will need to be ruled out before polymyalgia rheumatica is diagnosed.

What causes polymyalgia rheumatica?

The cause of polymyalgia rheumatica is unknown, but a combination of genetic and environmental factors is thought to be responsible.

Polymyalgia rheumatica is relatively common in the UK. It's estimated that one in every 1,200 people develop the condition every year.

Polymyalgia rheumatica is age-related. Most people who are diagnosed with the condition are over 70. It's extremely rare in people younger than 50. It's also more common in women than men.

Treating polymyalgia rheumatica

The main treatment for polymyalgia rheumatica is a coritcosteroid medication called prednisolone, which is used to help relieve the symptoms.

You'll initially be prescribed a high dose of prednisolone, which will be reduced gradually over time.

Most people with polymyalgia rheumatica will need to take a long-term course of corticosteroid treatment (lasting 18 months to two years) to prevent their symptoms returning.

 



Giant cell arteritis

Around one in five people with polymyalgia rheumatica develop a more serious condition called giant cell arteritis (also known as temporal arteritis), which can cause inflammation in the arteries of the head or neck, resulting in symptoms such as:



persistent severe headaches with scalp tenderness (the scalp is sore to touch)



pain in the jaw muscles when chewing



impaired vision, such as double vision or loss of vision



You should contact your GP immediately if you notice these symptoms.

Unlike polymyalgia rheumatica, giant cell arteritis requires immediate medical assistance and without prompt treatment it can cause permanent visual impairment.

The symptoms of giant cell arteritis can develop before, after or at the same time as the symptoms of polymyalgia rheumatica.

Symptoms of polymyalgia rheumatica  

The most common symptom of polymyalgia rheumatica (PMR) is pain and stiffness in the shoulder muscles, which develops quickly over a few days or weeks.

The muscles in the neck and hips are also often affected. Both sides of the body are usually affected.

The stiffness often feels worse first thing in the morning after you wake up and starts to improve after about 45 minutes as you become more active.

Some people with polymyalgia rheumatica have additional symptoms, including:



a mild high temperature (fever) of 37-38C (98.6-100.4F)



depression



fatigue (extreme tiredness)



loss of appetite



weight loss



When to seek medical advice

If you have symptoms of pain and stiffness that last longer than a week, you should make an appointment to see your GP so that the cause can be investigated.

When to seek immediate medical advice

You should seek immediate medical advice if you have been diagnosed with polymyalgia rheumatica (or the condition is suspected) and you suddenly develop:



a persistent and severe headache



jaw pain or cramping in your jaw muscles which is worse when you're eating



pain in the tongue when chewing 



vision loss or vision disturbances, such as double vision



These symptoms may indicate a more serious condition called giant cell arteritis (temporal arteritis).

Call your GP immediately for advice if you have any of the above symptoms. If this isn't possible, contact your local out of hours service or call 111.

Diagnosing polymyalgia rheumatica  

Diagnosing polymyalgia rheumatica (PMR) can often be quite a lengthy process that involves several different tests.

This is because the condition shares many symptoms with more common health conditions, such as rheumatoid arthritis, which need to be ruled out first.

Tests

There's no specific test for polymyalgia rheumatica, but it's likely that a series of blood tests will be carried out.

Two blood tests – erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – can be used to check the levels of inflammation in your body.

If the ESR and CRP test results are normal, it’s unlikely that polymyalgia rheumatica will be diagnosed because your doctor won’t want to prescribe a long-term course of steroids if the diagnosis is uncertain. Sometimes, the ESR may be normal and CRP may be raised, which would be more likely to indicate a positive diagnosis. This is why both tests are usually carried out at the same time.

As inflammation is a characteristic of many conditions, high levels don't automatically mean that you have polymyalgia rheumatica. Further tests may be needed to help rule out other conditions that cause inflammation. For example, a test for rheumatoid factor and anti-CCP antibodies, may be carried out to rule out rheumatoid arthritis.

Blood tests can also help determine:



whether there's an infection in your blood



how well some of your organs, such as your kidneys, are working



whether you have an overactive thyroid gland or an underactive thyroid gland (both conditions can cause muscle pain)



You may also have a urine test to check how well your liver is functioning.

X-rays and ultrasound scans may also be used to look at the condition of your bones and joints.

Symptom checklist

After other possible causes of your symptoms have been ruled out, a checklist can be used to see whether your symptoms match those most commonly associated with polymyalgia rheumatica.

A confident diagnosis of polymyalgia rheumatica can usually be made if you meet all of the following criteria:



you're over 50 years of age 



you have pain in your shoulders or your hips



you have stiffness in the morning that lasts longer than 45 minutes



your symptoms have lasted longer than two weeks



blood tests show raised levels of inflammation in your body



your symptoms rapidly improve after treatment with corticosteroids



Treating polymyalgia rheumatica 

Steroid medication (corticosteroids) is the preferred treatment for polymyalgia rheumatica (PMR).

A type of corticosteroid called prednisolone is usually prescribed.

Prednisolone

Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It doesn't cure polymyalgia rheumatica, but it can help relieve the symptoms.

When used to treat polymyalgia rheumatica, prednisolone is taken as a tablet. Most people will be prescribed several tablets to take once a day.

You'll be prescribed a high dose of prednisolone initially, and the dose will be gradually reduced every one to two months.

Although your symptoms should improve within a few days of starting treatment, you'll probably need to continue taking a low dose of prednisolone for about two years.

In many cases, polymyalgia rheumatica improves on its own after this time. However, there's a chance that the condition will return (relapse) once treatment stops.

Don't suddenly stop taking steroid medication unless a doctor in charge of your care tells you it's safe to do so. Suddenly stopping treatment with steroids can make you feel very ill.

Side effects of prednisolone

About one in 20 people who take prednisolone will experience changes in their mental state when they take the medication.

You may feel depressed and suicidal, anxious or confused. Some people also experience hallucinations (seeing or hearing things that aren't there). Contact your GP as soon as possible if you experience changes to your mental state. 

Other side effects of prednisolone include:



increased appetite that often leads to weight gain



increased blood pressure



mood changes, such as becoming aggressive or irritable with people



weakening of the bones (osteoporosis)



stomach ulcers



increased risk of infection, particularly with the varicella-zoster virus (the virus that causes chickenpox and shingles) 



Seek immediate medical advice if you think you've been exposed to the varicella-zoster virus, or if a member of your household develops chickenpox or shingles.

The risk of these side effects should improve as your dose of prednisolone is decreased.

See side effects of corticosteroids for more information about how these side effects may affect you and how they're treated.

Other medications

Sometimes, other medicines may be combined with corticosteroids to help prevent relapses or to allow your dose of prednisolone to be reduced.

Some people are prescribed immunosuppressant medication, such as methotrexate. This is used to reduce or suppress the immune system (the body's defence against infection and illness). It may be helpful for people with polymyalgia rheumatica who have frequent relapses or don't respond to normal steroid treatment.

Your doctor may recommend painkillers, such as paracetamol, or non-steroidal anti-inflammatory drugs (NSAIDs), to help relieve pain and stiffness while your dose of prednisolone is reduced.

Follow-up

Your GP will ask you to attend regular follow-up appointments to check how well you're responding to treatment, whether your dose of prednisolone needs to be adjusted, and how well you're coping with the side effects of the medication.

During these appointments, you'll have blood tests to check the levels of inflammation inside your body.

Follow-up appointments are usually recommended every few weeks for the first three months and then at three- to six-monthly intervals after this time.

Contact your GP if your symptoms return during any part of your treatment. Your dosage may need to be adjusted.

 

Steroid card

If you need to take steroids for more than three weeks, your GP or pharmacist should arrange for you to be issued with a steroid card.

The card explains that you're regularly taking steroids and your dose shouldn't be stopped suddenly. You should carry the card with you at all times.


Polymyalgia rheumatica