PMR

 PMR

By Peter Galvin, MD

Polymyalgia rheumatica (PMR) is an inflammatory disorder that causes muscle pain and stiffness. Individuals with PMR typically have pain and stiffness in the shoulders or hip area that often gets worse with rest and that may cause difficulty with daily activities such as rising from a chair, standing and walking, buttoning clothes, or lifting the arms upward. Fatigue, depression, night sweats, loss of appetite, weight loss, and low-grade fever may also occur with this disease. PMR affects more than 200,000 people in the U.S. aged 50 years and older and occurs more commonly in women. About 20% of patients also have giant cell arteritis, also called temporal arteritis. This condition, which is an inflammatory disorder of arteries, especially those near the temple, may cause headache, jaw pain and pain with chewing, and blurred or double vision which, if untreated, may cause blindness in the eye near the affected temple. Giant cell arteritis can also affect the aorta, causing aneurysms, dissection, or aortic rupture.

The diagnosis of PMR is typically made based on characteristic symptoms of muscle pain and stiffness and elevated markers of inflammation in the blood including elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). While there is no specific test to diagnose PMR, over 90% of patients with it will have these elevated inflammatory markers. In rare cases where the inflammatory markers are not elevated, ultrasound of the shoulders or hips may help diagnose inflammation (bursitis). The mainstay of treatment is reducing inflammation, usually achieved with oral glucocorticoids (steroids, i.e., prednisone). Initial dosing of prednisone is from 12.5 mg to 25 mg a day. Then, once symptoms subside, which typically takes about two to four weeks, the prednisone dose is very slowly reduced because steroids have serious side effects with prolonged use, such as osteoporosis, infections, cataracts, diabetes, and weight gain. The prednisone dosage should be lowered over six to nine months, after which many people can stop it without a recurrence of symptoms. If symptoms recur after the prednisone has been tapered or stopped, prednisone can be restarted or another drug, for example methotrexate, can be prescribed.

Patients with PMR who develop new-onset headaches and/or vision abnormalities should seek immediate medical care to evaluate for giant cell arteritis, which requires much higher steroid dosages, for example 1 mg per kilogram of weight, to decrease the risk of blindness in an eye. Also, patients with PMR being treated with steroids who develop new or worsening hip pain should be evaluated for avascular necrosis of the hip, a condition that leads to bony destruction of the hip joint, often necessitating hip replacement.

For more information, go to the website of the American College of Rheumatology at:

www.rheumatology.org

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