REMEDY : BNSSG referral pathways

Polymyalgia Rheumatica

Checked: 30-06-2017 by Rob.Adams Next Review: 13-06-2018

Principles of Management

UHB is no longer providing a specific Polymyalgia Rheumatica (PMR) clinic. Patients with PMR can be managed effectively in primary care, with support from the Rheumatology service as needed for complex patients.

Our local rheumatologists suggest GPs use the guidelines for The Management of PMR (2010) published by the British Society for Rheumatology.

The Rheumatology team at UHB will still accept referrals for any patients with atypical features of PMR, diagnostic uncertainty, or those with incomplete or non-response to glucocorticoids

BSR Guidelines

Diagnosis

Core inclusion criteria:

  • Age >50 years, duration >2 weeks

  • Bilateral shoulder or pelvic girdle aching, or both

  • Morning stiffness duration of >45 min

  • Evidence of an acute-phase response

PMR can be diagnosed with normal inflammatory markers, if there is a classic clinical picture and response to steroids. These patients should be referred for specialist assessment.

Core exclusion criteria:

  • Active infection

  • Active cancer

  • Active GCA

The presence of the following conditions decreases the probability of PMR, and they should also be excluded:

  • Other inflammatory rheumatic diseases

  • Drug-induced myalgia

  • Chronic pain syndromes

  • Endocrine disease

  • Neurological conditions, e.g. Parkinsons disease.

Investigations

Laboratory investigations before commencement of steroid therapy:

  • Full blood count

  • ESR/plasma viscosity and/or CRP

  • Urea and electrolytes

  • Liver function tests

  • Bone profile

  • Protein electrophoresis (also consider urinary Bence Jones Protein)

  • Thyroid stimulating hormone

  • Creatine kinase

  • RF (ANA and anti-CCP antibodies may be considered)

  • Dipstick urinalysis

  • Chest X-ray may be required

Treatment

In the absence of GCA, urgent steroid therapy is not indicated before the clinical evaluation is complete.  The suggested regimen is:

  • Daily prednisolone 15mg for 3 weeks

  • Then 12.5mg for 3 weeks

  • Then 10mg for 4–6 weeks

  • Then reduction by 1mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5mg alternate days, etc.)

However, there should be a flexible approach to this regime if needed. Usually 1–2 years of treatment is needed. The need for ongoing therapy after 2 years of treatment should prompt the consideration of an alternative diagnosis, and referral for specialist evaluation.

Bone protection

Individuals with high fracture risk, e.g. aged 65 years or older, or prior fragility fracture

Bisphosphonate with calcium and vitamin D supplementation. DEXA not required

Other individuals - Calcium and vitamin D supplementation when starting steroid therapy. DEXA scan recommended.

Individuals requiring higher initial steroid dose - Bisphosphonate with calcium and vitamin D supplementation (because higher cumulative steroid dose is likely)