Management of polymyalgia rheumaticaBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c620 (Published 04 February 2010) Cite this as: BMJ 2010;340:c620
Evidence is lacking on the management of polymyalgia rheumatica.1 The recent guidelines published by the British Society for Rheumatology (BSR) and the British Health Professionals in Rheumatology (BHPR) are a brave attempt to give some structure to the diagnosis and treatment of this condition.2
Polymyalgia rheumatica is one of the most common inflammatory rheumatic diseases in elderly people. It is characterised by pain and stiffness, usually of sudden onset, affecting the limb girdle areas (shoulder and hip), neck, and torso.3 Its prevalence in people aged over 50 is about 700 per 100 000.4 It has many non-specific features and a wide differential diagnosis. No “gold standard” diagnostic test is available, so the diagnosis is often made on clinical grounds. This can lead to diagnostic error.
Polymyalgia rheumatica is managed mainly in primary care but also in secondary care by rheumatologists and other specialists.5 It is one of the most common indications for long term steroid use in the community, accounting for 22% of prescriptions.6 Despite being so common, there is surprisingly little sound evidence from randomised controlled trials on which to base diagnosis and management.
The new guidelines are aimed at healthcare practitioners in primary and secondary care, and they are intended to be used in the evaluation of patients with new symptoms of proximal bilateral shoulder or hip pain. A framework for the subsequent management of patients in primary care with regard to treatment, monitoring, and indications for early specialist referral is also outlined.
The guidelines recommend that the diagnosis of polymyalgia rheumatica is based on the presence of the following criteria: the patient is over 50 years of age, duration of symptoms is longer than two weeks, presence of bilateral shoulder or pelvic girdle aching, morning stiffness lasting longer than 45 minutes, and evidence of an acute phase response. It is crucial to exclude active infection, cancer, and other inflammatory conditions. Giant cell arteritis should always be considered because it occurs in 16-21% of patients with polymyalgia rheumatica.7
The suggested treatment regimen is prednisolone 15 mg for three weeks, which is then gradually tapered. Intramuscular methylprednisolone may also be used. Treatment usually lasts for one to two years. However, this guidance should not be regarded as absolute because it is supported by only grade B evidence.
Response to steroids is widely used as a defining feature of polymyalgia rheumatica. Vigilant monitoring and evaluation of the response to corticosteroids is recommended, and in typical cases at least a 70% improvement in symptoms is expected. The response is assessed after one to three weeks by evaluating the global response to relevant symptoms (proximal pain, stiffness), and the diagnosis is confirmed after four to six weeks.2
Early referral to a specialist is advised in cases with atypical features such as age less than 60 years, chronic onset, lack of shoulder involvement or inflammatory stiffness, or “red flag” features such as prominent systemic symptoms (weight loss or night pain). In addition, specialist input is suggested in patients with a normal or very high acute phase response and when encountering treatment problems such as lack of response to steroids or contraindications to steroids.2
No other validated international guidelines are available for the diagnosis and treatment of this condition. Diagnostic and classification criteria are currently being developed.5 8 9 Clinical and patient oriented outcomes have been defined but still need validation by good quality trials.
The current guidelines simplify the approach to the diagnosis and management of patients presenting with polymyalgic symptoms, although they are not supported by good scientific evidence—most of the recommendations are graded at level B or C. Until further research is available, many unanswered questions remain.
Cite this as: BMJ 2010;340:c620
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.