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eMedicine Specialties > Emergency Medicine > Rheumatology

Polymyalgia Rheumatica

Geofrey Nochimson, MD, Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital

Updated: Sep 24, 2008

Introduction

Background

Polymyalgia rheumatica (PMR) is a clinical syndrome characterized by severe aching and stiffness in the neck, shoulder girdle, and pelvic girdle. It is classified as a rheumatic disease, although the etiology is undetermined.

Pathophysiology

PMR causes severe pain in the proximal muscle groups; however, no evidence of disease is present at muscle biopsy. Muscle strength and electromyographic findings are normal. Some evidence suggests the presence of cell-mediated injury to the elastic lamina in the blood vessels in the affected muscle groups.

PMR is closely linked to giant cell arteritis (temporal arteritis), but this is believed to be a separate disease process.

Frequency

United States

One study revealed a prevalence of 1 in 200 people aged 50 years or older.

Mortality/Morbidity

PMR is not a life-threatening disease, but it does require treatment for 2-4 years.

Race

Whites are affected more than other ethnic groups.

Sex

Females are affected twice as often as males.

Age

PMR usually affects people older than 50 years.

Clinical

History

The patient's history may include the following features:

  • Pain and stiffness in the proximal muscle groups that usually is symmetrical and worse in the morning
  • Gel phenomenon (stiffness after prolonged inactivity)
  • Fever (low grade)
  • Weight loss
  • Fatigue
  • Depression
  • No weakness
  • Abrupt onset of symptoms

Physical

The signs and symptoms of PMR are nonspecific, and objective findings on physical examination often are lacking. If present, findings may include the following:

  • No muscle atrophy
  • Muscle tenderness
  • Decreased active range of motion of joints secondary to pain

Causes

The etiology is unknown; however, risk factors include the following:

  • Age of 50 years or older
  • Presence of giant cell arteritis

Differential Diagnoses

Arthritis, Rheumatoid
Depression and Suicide
Hypothyroidism and Myxedema Coma
Polymyositis
Systemic Lupus Erythematosus
Temporal Arteritis

Other Problems to Be Considered

Dermatomyositis
Fibromyalgia
Osteoarthritis
Occult infection
Myopathy

Workup

Laboratory Studies

The following laboratory studies should be obtained for suspected polymyalgia rheumatica:

  • Erythrocyte sedimentation rate greater than 50 mm/h
  • Normochromic normocytic anemia in 50% of cases
  • Normal creatinine kinase level
  • Negative finding for rheumatoid factor
  • Mild elevations with liver function test results
  • Mild nonspecific synovitis
  • Negative muscle biopsy findings

Treatment

Emergency Department Care

  • No emergent therapy is required for polymyalgia rheumatica.
  • Physical therapy may be administered for range of motion, if necessary.

Consultations

Consult the primary care physician and/or a rheumatologist.

Medication

The goal of therapy is to suppress autoimmune activity.

Corticosteroids

These agents have anti-inflammatory properties and may cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Orasone, Sterapred)

Useful in the treatment of inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, it may decrease inflammation. PMR is rapidly responsive to low doses of prednisone. Patients may require treatment for several months to several years.

Dosing

Adult

5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve

Pediatric

4-5 mg/m2/d or 1-2 mg/kg PO qd; taper over 2 wk as symptoms resolve

Interactions

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Follow-up

Further Outpatient Care

  • For patients with polymyalgia rheumatica, perform follow-up monthly initially and during steroid tapering, then follow up quarterly.
  • Monitor erythrocyte sedimentation rate while the patient is receiving steroids.

Complications

Complications of polymyalgia rheumatica may include the following:

  • Complications related to steroid therapy
  • Exacerbation of disease with taper of steroids

Prognosis

  • The average length of disease is 3 years.
  • Exacerbations may occur if steroids are tapered too rapidly.
  • Relapse is common.

Patient Education

  • Educate the patient about precautions with steroid use.
  • For excellent patient education resources, visit eMedicine's Muscle Disorders Center. Also, see eMedicine's patient education articles, Chronic Fatigue Syndrome and Chronic Pain.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider giant cell arteritis
  • Failure to strongly consider other diagnoses in patients younger than 50 years
  • Failure to prescribe prednisone for a patient in whom PMR is strongly suspected

References

  1. Collier J. The management of polymyalgia rheumatica and giant cell arteritis. Drug Ther Bull. 1993;31:65-7.

  2. Dasgupta B, Matteson EL, Maradit-Kremers H. Management guidelines and outcome measures in polymyalgia rheumatica (PMR). Clin Exp Rheumatol. Nov-Dec 2007;25(6 Suppl 47):130-6. [Medline].

  3. Epperly TD, Moore KE, Harrover JD. Polymyalgia rheumatica and temporal arthritis. Am Fam Physician. Aug 15 2000;62(4):789-96, 801. [Medline].

  4. Evans JM, Hunder GG. Polymyalgia rheumatica and giant cell arteritis. Rheum Dis Clin North Am. Aug 2000;26(3):493-515. [Medline].

  5. Gonzalez-Gay MA. Giant cell arteritis and polymyalgia rheumatica: two different but often overlapping conditions. Semin Arthritis Rheum. Apr 2004;33(5):289-93. [Medline].

  6. Kyle V, Hazleman BL. The clinical and laboratory course of polymyalgia rheumatica/giant cell arteritis after the first two months of treatment. Ann Rheum Dis. Dec 1993;52(12):847-50. [Medline].

  7. Michet CJ, Matteson EL. Polymyalgia rheumatica. BMJ. Apr 5 2008;336(7647):765-9. [Medline].

  8. Miller D, Allen SE, Walker SE. A primary care physician's guide to polymyalgia rheumatica. Primary Care Rep. 1998;4:91-100.

  9. Pipitone N, Salvarani C. Systemic vasculitis: state of the art and emerging concepts. Curr Opin Rheumatol. Jan 2006;18(1):1-2. [Medline].

  10. Rodnan GP, Schumacher HR. Polymyalgia rheumatic and temporal arteritis. In: Primer on the Rheumatic Diseases. 1990:76-7.

  11. Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. Jul 19 2008;372(9634):234-45. [Medline].

  12. Scientific American Editors. Systemic Vasculitis [book on CD-ROM]. 1995.

  13. Weyand CM, Goronzy JJ. Giant-cell arteritis and polymyalgia rheumatica. Ann Intern Med. Sep 16 2003;139(6):505-15. [Medline].

Keywords

polymyalgia rheumatica, PMR, giant cell arteritis, rheumatic disease, temporal arteritis, stiffness, aching, pain in the proximal muscle groups, stiffness in the proximal muscle groups, Gel phenomenon, stiffness after prolonged in activity

Contributor Information and Disclosures

Author

Geofrey Nochimson, MD, Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital
Geofrey Nochimson, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

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