Polymyalgia Rheumatica

As with GCA, polymyalgia rheumatica usually occurs in whites older than 50 years, especially those of northern European ancestry. Constitutional symptoms such as fever, fatigue, malaise, and weight loss occur early on, followed by neck and proximal upper extremity muscle aches. PMR is sometimes misdiagnosed as a frozen shoulder because of this. PMR later involves the lower extremity proximal muscles of the hips and thighs. Morning stiffness of large joints can make it difficult for the patient to perform ADLs, such as getting out of bed or combing the hair. The only typical physical finding is muscle tenderness, but without other objective signs. A transient mild synovitis of the knees, wrists, and sternoclavicular joints might occur. Diagnosis is made clinically by noting the combination of proximal extremity and truncal muscle pain and stiffness, increased ESR, and response to steroids.

Both PMR and GCA (temporal arteritis) are often seen together. PMR can precede, appear simultaneously with, or follow the onset of GCA symptoms. These two conditions might represent different manifestations of the same pathologic process. The best treatment for PMR is corticosteroids, with the dose determined by patient characteristics as well as by whether GCA is present. The typical dose is 15 to 30 mg/day of prednisolone; the daily dose is reduced by 5 mg/ week until the dose is 15 mg/day, at which point the dosage is decreased by 2.5 mg/month.

Treatment can be stopped after 6 to 12 months if the ESR remains normal and the patient remains asymptomatic at a daily dose of 2.5 mg. Serial ESRs should be performed every 2 to 3 weeks, although following the patient's symptoms closely is more important than simply following laboratory values. For recurrences, 15 mg of prednisolone is restarted and gradually tapered. NSAIDs might help relieve symptoms but do not protect against vasculitis.

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