Background Information

Clinical Features

Suspect PMR in >50 y/o with at least 2 weeks of core symptoms:

• Bilateral shoulder and/or pelvic pain that worsens with movement and affects sleep
  • Usually unilateral initially but quickly becomes bilateral
  • Shoulder pain may radiate to the elbows and is the presenting feature (70-95%)

• Stiffness lasting >45 min after waking or resting
  • May cause difficulty in turning over in bed / rising from bed or chair / raising arms above shoulder height

Additional features:

• Systemic features – fever, fatigue, anorexia, weight loss, depression
• Peripheral MSK signs
  • Carpal tunnel syndrome
  • Asymmetric peripheral arthritis
  • Oedema of the hands, wrists, feet, ankles
• Bilateral upper arm tenderness

Guidelines

Investigation and Diagnosis

There are no clear diagnostic criteria for PMR, NICE CKS states that diagnosis is made by:

• Core clinical features, and
• Excluding PMR mimics, and
• +ve response to steroids

1st line test: ESR and/or CRP

• Raised inflammatory markers support PMR
• But not necessary for diagnosis, if clinical features are typical and inflammatory markers are normal, the diagnosis can still be made

Work Up

The following must be excluded:

• Giant cell arteritis – as immediate high-dose steroids is necessary
• Active infection / cancer
• Other PMR mimics
  • Arthritis
  • Thyroid disease
  • Statin-induced myalgia
  • Myositis

To exclude PMR mimics, perform the following tests before starting steroids:

• FBC, U&E, LFT
• Calcium, ALP
• Protein electrophoresis
• TSH
• Creatine kinase
• Rheumatoid factor
• Urinalysis

Management

1st line: trial of oral prednisolone 15mg daily

• Assess clinical response after 1 week
• Check ESR and/or CRP after 3-4 weeks to assess response
• Arrange routine reviews 1 week after any changes to steroid dose and at least 3 monthly in the first year following diagnosis

Only start tapering steroid dose slowly once symptoms are fully controlled.

References

Original Guideline