OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• rheumatology
• Vic. DHS Better Health Channel - patient fact sheet on PMR

• PMR is a clinical syndrome characterized by severe aching and stiffness in the neck, shoulder girdle, and pelvic girdle.
• closely linked to temporal arteritis (giant cell arteritis)
  • 25% of patients with PMR experience temporal arteritis, and if this is present there is a risk of damage to the arteries of the eye which can rapidly lead to blindness.
  • 50% of patients with temporal arteritis will have PMR at the same time.
• mainly a condition of those older than 50 years in whom it affects 1 in 200, but particularly females (M:F ratio 1:2), aged over 70 years.

• pain and aching of proximal muscle groups (hip/pelvis/shoulders/neck in particular), usually worse in the morning or after inactivity and of relatively abrupt onset
• non-specific clinical findings
• general constitutional symptoms of malaise, fatigue, low grade fevers, weight loss
• muscle tenderness but no weakness or atrophy
• rare complications include stroke (CVA) and abdominal aortic aneurysm (AAA)

• bilateral shoulder or pelvic girdle aching – or both
• morning stiffness longer than 45 minutes
• age older than 50 years
• duration >2 weeks
• evidence of an acute phase response (raised ESR and/or raised CRP)

• rheumatoid arthritis
• depression
• hypothyroidism
• polymyositis
• systemic lupus erythematosus (SLE)
• dermatomyositis
• fibromyalgia
• osteoarthritis
• occult infection
• myopathy / myositis / muscle aches and pains
• statin-induced proximal myopathy

• erythrocyte sedimentation rate (ESR) > 50 mm/h
• C reactive protein (CRP) > 60mg/L
• normochromic normocytic anaemia in 50% of cases
• normal creatinine kinase level (thus excludes myositis)
• negative finding for rheumatoid factor (thus makes rheumatoid arthritis less likely)
• mild elevations in liver function test results
• mild nonspecific synovitis
• negative muscle biopsy findings
• US may reveal multiple bursitis and tendonitis in the shoulder regions

• atypical features
  • age < 60yrs
  • chronic onset > 2 months
  • lack of shoulder involvement
  • lack of inflammatory stiffness
  • prominent systemic features of weight loss, night pain, or neurologic signs
  • features of other rheumatic disease
  • normal or extremely high acute phase response (ie. ESR or CRP)
• treatment issues
  • incomplete or poor response to steroids
  • inability to taper steroids
  • C/I to steroids
  • prolonged steroid Rx > 2yrs

• check for temporal arteritis
• prednisolone
  • usual starting dose should be around 0.2mg/kg (ie. 12.5-15mg mane for most 60-70kg patients) ^{1) 2) 3)}
  • may need higher dose if not responding within 7-14 days although some 25% do not respond to steroids
  • once responded, and ESR, CRP have fallen to much lower levels, then taper dose eventually hopefully a daily dose of 1mg/d may suffice, but may need Rx for 2-3 years
  • example regime for average body weight patients assuming adequate responses:
    • 15mg/d for 3wks followed by weaning plan thereafter: 12.5mg for 3wks, then 10mg for 4wks, and then reduce by 1mg every month
• consider non-steroidal anti-inflammatory drugs (NSAIDs)
• referral to rheumatologist
• monitor erythrocyte sedimentation rate (ESR) to help guide prednisolone dosing
• usually need monthly review then quarterly to watch for response to steroids and their complications.
• exacerbations occur if steroid dose tapering is too rapid