Polymyalgia Rheumatica (PMR)

  • Medical Author:
    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

  • Medical Editor: Catherine Burt Driver, MD
    Catherine Burt Driver, MD

    Catherine Burt Driver, MD

    Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.

Polymyalgia rheumatica (PMR) facts

  • Polymyalgia rheumatica (PMR) is a disease that causes pain and stiffness in muscles and joints.
  • Health care professionals diagnose PMR by characteristic common symptoms associated with abnormal blood testing for inflammation.
  • Treatment of PMR involves taking low doses of cortisone medications.

What is polymyalgia rheumatica?

Polymyalgia rheumatica is a disease of the muscles and joints characterized by muscle pain and stiffness, affecting both sides of the body, and involving the shoulders, arms, neck, and buttock areas. People with the disease are typically over 50 years of age. Polymyalgia rheumatica is abbreviated PMR.

PMR and temporal arteritis (giant cell arteritis) sometimes occur in the same patient. About 10%-15% of people with PMR also have giant cell arteritis.

What are polymyalgia rheumatica causes and risk factors?

The cause of the condition is not known. Recent research has indicated that genetic (inherited) risk factors play a role in who becomes afflicted with the illness. Theories include viral stimulation of the immune system in genetically susceptible individuals. Rarely, the disease is associated with a cancer. In this setting, the cancer may be initiating an inflammatory immune response to cause the polymyalgia rheumatica symptoms.

What are common symptoms and signs of polymyalgia rheumatica?

The onset of the disease can be sudden. A patient may have a healthy history until awakening one morning with stiffness and pain of muscles and joints throughout the body. These pains can lead to a sensation of weakness and loss of function. Sometimes there is also muscle tenderness with PMR. These clinical symptoms persist and often include an intense sensation of fatigue. Some patients notice a gradual loss of appetite accompanied by weight loss and lack of energy. Depression can occur.

How do health care professionals make a diagnosis of polymyalgia rheumatica?

The diagnosis of the disorder is suggested by the health history and physical examination. A health care professional frequently notes muscle tenderness and that the motion of the shoulders is limited by pain. The joints are usually not swollen. However, signs such as swelling of the small joints of the hands, wrists, and/or knees can occur. Blood testing for inflammation is generally abnormal, as indicated by a significant elevation in the erythrocyte sedimentation rate (sed rate or ESR) and/or C-reactive protein. There are no specific tests, however, for the condition and X-rays are normal. The diagnosis is based on the characteristic history of persisting muscle and joint pain and stiffness associated with elevated blood tests for inflammation, such as the ESR. It is also not unusual for patients to have slight elevations of liver blood tests.

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Polymyalgia Rheumatica (PMR) Complication

Temporal Arteritis (Giant Cell Arteritis)

Giant cell arteritis, also called temporal arteritis or cranial arteritis, is a serious disease characterized by inflammation of the walls of the blood vessels (vasculitis). The vessels affected are the arteries (hence the name "arteritis"). Giant cell arteritis occurs in 10%-15% of patients with polymyalgia rheumatica. The age of affected patients is over 50 years of age, identical to that of polymyalgia rheumatica.

What is the medical treatment for polymyalgia rheumatica?

Doctors direct their medical treatment of PMR toward reducing pain and inflammation. While some patients with mild symptoms can improve with nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Motrin, Advil), most patients respond best to low doses of corticosteroids (such as prednisone or prednisolone). Not infrequently, a single day of cortisone medicine eases many of the symptoms! In fact, the rapid, gratifying results with low dose corticosteroids is characteristic of the condition.

The dose of prednisone is gradually reduced while the doctor monitors the symptoms and normalization of the blood ESR. Reactivation of symptoms can require periodic adjustments in the prednisone dosage. Most patients are able to completely wean from prednisone within several years. Some patients require longer-term medical treatment. Occasionally, patients have recurrence years after the symptoms have resolved. The ideal prednisone dosing regimen continues to be sought by clinical researchers.

What is the prognosis for patients with polymyalgia rheumatica?

The outlook for patients with isolated polymyalgia rheumatica is ultimately very good.

One of the keys to successful treatment of polymyalgia rheumatica is gradual, and not rapid, tapering of the medicines. This can avoid unwanted flare-ups of the disease.

Because the medicines prednisone and prednisolone are associated with potential bone toxicity, causing osteoporosis, patients should consider calcium and vitamin D supplementation. Bone mineral density testing should be performed in appropriate patients, and doctors may consider prescribing osteoporosis medicines, such as estrogen, alendronate (Fosamax), and risedronate (Actonel) for some.

Is it possible to prevent polymyalgia rheumatica?

There is no prevention for polymyalgia rheumatica. Prevention measures focus on preventing side effects of drugs used to treat polymyalgia rheumatica.

What are polymyalgia rheumatica complications?

Polymyalgia rheumatica can lead to loss of function of joints if untreated. This generally is temporary, but frozen shoulders can be a further medical complication. Additional complications can result from medications used to treat polymyalgia rheumatica. These include stomach bleeding or kidney impairment from nonsteroidal anti-inflammatory drugs and cataracts, bruising of skin, and osteoporosis from cortisone medications. Therefore, the lowest possible doses of medications are best.

Polymyalgia rheumatica can occur in association with giant cell arteritis (temporal arteritis). Giant cell arteritis is a potentially more serious condition. It can also occur, as mentioned above, in association with a cancer. The prognosis in this setting is based on the ability to cure the cancer. The polymyalgia rheumatica symptoms resolve with resolution of the cancer.

REFERENCE:

Firestein, Gary S., et al. Kelley's Textbook of Rheumatology, 9th Edition. Philadelphia, PA: Saunders, 2013.

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Reviewed on 10/27/2017
References
REFERENCE:

Firestein, Gary S., et al. Kelley's Textbook of Rheumatology, 9th Edition. Philadelphia, PA: Saunders, 2013.

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