Diagnosis and Treatment of Polymyalgia Rheumatica

Diagnosis

The American College of Rheumatology suggests that PMR should be suspected in patients over 60 years old presenting with bilateral shoulder and hip girdle pain and morning stiffness lasting more than 45 minutes, accompanied by elevated inflammatory markers (ESR >40 mm/hr or elevated CRP) 1
Age ≥60 years is a critical criterion for diagnosing PMR; younger patients warrant specialist referral for atypical presentation 1
Bilateral shoulder and hip girdle pain with morning stiffness is the hallmark symptom of PMR 1
Elevated ESR (>40 mm/1st hour) or CRP supports the diagnosis of PMR, though low inflammatory markers should prompt consideration of alternative diagnoses 1

The European League Against Rheumatism recommends starting prednisone at 12.5-25 mg daily as first-line therapy, with the specific dose individualized based on body weight, relapse risk, and comorbidity profile 2
Use 20-25 mg/day for patients with high risk of relapse (female sex, ESR >40, peripheral arthritis) and low risk of adverse events 1, 2
Use 12.5-15 mg/day for patients with relevant comorbidities (diabetes, osteoporosis, glaucoma) and risk factors for glucocorticoid-related side effects 2

Taper prednisone to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation, provided remission is maintained 1, 2
Decrease by 1 mg every 4 weeks during the maintenance tapering phase 1, 2

For relapse, increase prednisone to the pre-relapse dose, then taper more slowly (over 4-8 weeks) back to the dose at which relapse occurred, followed by reduction of 1 mg per month 3, 2

Add methotrexate 7.5-10 mg weekly for patients with frequent relapses, prolonged therapy requirements, or significant glucocorticoid-related adverse effects 2
Indications for methotrexate include multiple or frequent relapses, high risk factors for relapse, and risk factors for glucocorticoid adverse events 1, 2, 3

Schedule visits every 4-8 weeks during the first year, every 8-12 weeks in the second year, and as needed for relapses or dose adjustments 1, 2
At each visit, assess clinical symptoms, inflammatory markers, glucocorticoid-related adverse effects, and risk factors for relapse 1, 2, 3

Initiate bone protection at treatment start, as prednisone causes significant bone loss 2
Provide education on disease impact, treatment expectations, and comorbidity management, and recommend individually tailored exercise programs 1