B-QuiCK: Polymyalgia rheumatica (PMR)

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B-QuiCK: Polymyalgia rheumatica (PMR)

Assessment and diagnosis

A diagnosis of PMR is made clinically based on recognition of a history of characteristic symptoms, with a raised CRP or ESR, exclusion of other conditions which may mimic the history (e.g. rheumatoid arthritis) and a rapid response to oral corticosteroid treatment (click here for a diagnostic overview).

  • Take a history and perform a physical examination. Ask about:
    • Shoulder, neck, arm, elbow, hip, knee and lower back pain. Pain is usually bilateral and symmetrical and often present at night. There may be tenderness on examination.
    • Morning stiffness persisting for at least 30 – 45 minutes, and whether this interferes with daily activities, e.g. getting dressed, rising from a chair. Stiffness and pain typically lessen over the course of the day but may worsen after rest or with inactivity.
    • Peripheral symptoms, i.e. pain or stiffness in distal joints. Examine the hands, feet, knees and elbows for signs of joint inflammation.
    • Any systemic symptoms, e.g. low-grade fever, fatigue, loss of appetite, malaise and weight loss
  • Request CRP (if normal, request ESR), full blood count, serum creatinine and electrolytes, urinalysis (dipstick) and liver function tests
    • Request additional laboratory tests to exclude other potential diagnoses depending on symptoms and signs, e.g. TSH, rheumatoid factor/anti-CCP antibodies, serum creatine kinase (if polymyositis suspected)
  • Imaging, e.g. X-ray, ultrasound, is not usually required as findings are often unremarkable in PMR, however, may be useful if the diagnosis is uncertain

Always consider giant cell arteritis. GCA must be treated urgently to prevent ischaemic complications, e.g. permanent blindness. Symptoms or signs include new onset or type of headache, temporal artery or scalp tenderness, jaw claudication and visual symptoms. If GCA is suspected, refer the patient for an urgent temporal artery biopsy (or discuss with the rheumatology service according to local protocols) and initiate high dose oral corticosteroids.


  • An oral corticosteroid, usually prednisone, is recommended first-line for patients with PMR
  • Use the lowest effective dose of prednisone between 12.5 – 25 mg:
    • 15 mg is usually an appropriate starting dose
    • A lower dose may be needed for patients with mild symptoms, relevant co-morbidities, risk factors for corticosteroid-related adverse effects or frailty
    • A slightly higher dose may be required for patients with severe initial symptoms or a larger body weight
  • The dose should be taken once daily in the morning. Trial a twice daily divided dose if the patient experiences significant symptoms by the end of the day (although taking corticosteroids in the evening can disrupt sleep).
  • If corticosteroids are contraindicated or ineffective, discuss an alternative (e.g. methotrexate) in consultation with a rheumatologist

Follow-up and ongoing monitoring

  • Regularly review the patient to assess response to treatment, adjust dose of corticosteroid as required, and monitor for any symptoms and signs of relapse, corticosteroid-related adverse effects or the development of GCA
    • Request laboratory tests as indicated based on clinical judgment to provide supporting information, e.g. CRP (or ESR), FBC, serum creatinine and electrolytes, HbA1c (if risk factors for diabetes)
  • Follow-up more frequently to begin with and reduce over time if the patient is responding well to treatment
    • E.g. review at Week 1 - 2 (or earlier if there has been no response within a few days or if symptoms worsen), Weeks 3, 6 and 12, and then every 6 to 12 months (or when there is symptom relapse)
  • Clinical response to prednisone is assessed based on return to function, e.g. ability to perform movements and tasks that were previously impaired (such as getting out of a chair). Expect improvement to begin within a few days to one week of treatment initiation.
    • CRP (or ESR) levels should normalise within two to four weeks (however inflammatory marker levels may not always correlate with the patient’s symptomatic response)
  • Reconsider the diagnosis if there is inadequate response to prednisone within seven to ten days. If clinical suspicion for PMR remains, trial a higher prednisone dose after discussing with a rheumatologist.
  • Gradually taper the corticosteroid dose once there is adequate symptom improvement (usually after two to four weeks); the rate of taper should be done primarily in response to symptoms, not CRP (or ESR) results alone
    • If a relapse occurs, increase the dose back to pre-relapse levels before re-attempting a gradual taper. After two relapses, methotrexate may be added to the treatment regimen in consultation with a rheumatologist.
  • Reconsider the diagnosis of PMR if treatment cannot be completely stopped; refer the patient to a rheumatologist if uncertain
  • Monitor for, prevent and treat any adverse effects of corticosteroids (see Table). Long-term treatment decisions are individualised, taking into consideration the adverse effects associated with prolonged corticosteroid use.
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