Polymyalgia Rheumatica (PMR) Referral Guideline

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Patients with typical presentation, who have a complete, sustained response to low-dose corticosteroids, and who have no adverse events can be managed in primary care.

History

  • 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 (e.g. raised ESR, CRP)

Examination

  • Shoulder, neck and hip range of movements - reduced
  • Muscle strength - normal
  • Patients should be assessed for evidence of GCA:
    • Temporal artery – tenderness, thickening, beading, reduced or absent pulsation
    • Scalp tenderness
    • Peripheral pulses upper extremities – diminished or lack
    • Auscultation of subclavian, axillary, brachial arteries – bruits
    • Blood pressure on both arms – discrepancy of more than 20mmHg in systolic pressure
    • If visual symptoms - vision acuity, eye movements, visual fields.

Helpful Investigations

  • FBC, U&E, LFT, bone profile, ESR, CRP, plasma viscosity
  • Immunoglobulins and electrophoresis (consider Bence Jones protein)
  • TFTs
  • CK
  • Rheumatoid factor (anti-nuclear antibody may also be considered)
  • CXR (if prominent systemic symptoms)
  • Dipstick urinalysis

Primary Care Management

  • Corticosteroids should be initiated and tapered as follows:
    • Daily prednisolone 15mg for 3 weeks
    • Then 12.5mg for 3 weeks
    • Then 10mg for 4-6 weeks
    • Followed by reduction by 1mg every 4–8 weeks
    • Usually 1-2 years of steroid treatment is needed.
  • Bone protection (weekly bisphosphonate and calcium or vitamin D supplementation).

Assess for corticosteroid-related adverse events: weight gain, diabetes, osteoporosis, hypertension and lipid dysregulation.

Who to Refer

  • Atypical features:
    • Younger patient < 60 years
    • Chronic onset (>2 weeks)
    • Lack of shoulder involvement
    • Lack of inflammatory stiffness
    • Red flag features: prominent systemic features, weight loss, night pain, neurological signs
    • Peripheral arthritis or other features of CTD or muscle disease
    • Normal or very high ESR/CRP.
  • Treatment dilemmas such as:
    • Incomplete or non-response to corticosteroids
    • Ill-sustained response to corticosteroids
    • Unable to reduce corticosteroids
    • Contraindications to corticosteroid therapy
    • The need for prolonged corticosteroid therapy (>2 years).

Who Not to Refer

  • Patients who have no atypical features, who have a complete sustained response to low-dose corticosteroids, and who have no adverse events.
  • Patients with alternative diagnosis more likely:
    • Active infection and cancer
    • Drug-induced myalgia, e.g. statins
    • Pain syndromes, e.g. fibromyalgia
    • Endocrine, e.g. thyroid
    • Neurological, e.g. Parkinson’s disease
    • OA, degenerative and other peri-articular conditions of the shoulder, neck and hips.

For More Information

Dasgupta B., Borg F.A., Hassan N., Barraclough K., Bourke B., Fulcher J., Hollywood J., Hutchings A., Kyle V., Nott J., Power M., Samanta A. ; BSR and BHPR Standards, Guidelines and Audit Working Group. (2010) BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology, 49(1), pp. 86-90. DOI: https://doi-org.knowledge.idm.oclc.org/10.1093/rheumatology/kep303a.

Last reviewed: 01 November 2020

Next review: 01 November 2022

Author(s): Dr Anna Ciechomska

Co-Author(s): Rheumatology team: Dr Robin Munro, Dr Karen Donaldson, Dr Elizabeth Murphy, Dr James Dale, Dr Sanjiv Nandwani, Dr Georgiana Young, Dr May Chee, Mr Nico Groenendijk; GP representatives: Dr Tyra Smith, Dr Mark Russell, Dr Linda Findlay, Dr Paul Deehan, Dr Lucy Munro; Medical directorate: Dr Mehrdad Malekian

Approved By: Dr Karen Donaldson

Reviewer Name(s): Dr Anna Ciechomska