Polymyalgia Rheumatica: Causes, Symptoms and Treatment
Polymyalgia rheumatica is an inflammatory rheumatic condition that primarily affects older adults, causing significant pain and stiffness in the shoulders, neck, and hips.
Things worth knowing about "Polymyalgia Rheumatica"
Polymyalgia rheumatica is an inflammatory rheumatic condition that primarily affects older adults, causing significant pain and stiffness in the shoulders, neck, and hips.
What is Polymyalgia Rheumatica?
Polymyalgia rheumatica (PMR) is an inflammatory condition belonging to the rheumatic diseases, predominantly affecting people over the age of 50. The name derives from Greek and roughly translates to pain in many muscles. Despite this name, the inflammation in PMR does not originate in the muscles themselves but rather in the joints and surrounding bursae (fluid-filled sacs). PMR is one of the most common inflammatory rheumatic conditions in older adults.
Causes
The exact cause of polymyalgia rheumatica has not yet been fully established. A combination of factors is believed to be involved:
- Genetic predisposition: Certain gene variants, particularly in the HLA gene region (Human Leukocyte Antigen), appear to increase the risk of developing PMR.
- Immune system dysfunction: The immune system mistakenly targets the body's own tissue, triggering inflammation.
- Environmental triggers: Viral infections may act as a trigger in some individuals.
- Age: PMR occurs almost exclusively in people over 50, with the peak incidence between the ages of 70 and 80.
Symptoms
The symptoms of polymyalgia rheumatica often appear suddenly and are quite characteristic:
- Pain and stiffness in the shoulders, neck, and hips
- Morning stiffness that typically lasts longer than 45 minutes
- Reduced range of motion, such as difficulty lifting the arms or rising from a chair
- General feeling of illness, fatigue, and malaise
- Unintentional weight loss and low-grade fever
- Nighttime pain that disrupts sleep
It is important to note that in PMR, the muscles themselves are not inflamed. The pain arises from inflammation within joint capsules and bursae.
Diagnosis
The diagnosis of polymyalgia rheumatica is primarily clinical, as there is no single definitive test. The following investigations are typically used:
- Blood tests: Elevated inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are characteristic. Mild anemia may also be present.
- Imaging: Ultrasound or MRI of the affected joints can reveal inflammation in bursae and tendon sheaths.
- Classification criteria: The 2012 ACR/EULAR classification criteria help confirm the diagnosis.
- Exclusion of other conditions: Conditions such as rheumatoid arthritis, myositis, or malignancies must be ruled out.
An important consideration is the close association between PMR and giant cell arteritis (temporal arteritis). Up to 20% of PMR patients develop giant cell arteritis concurrently or during the course of their illness, which can lead to serious complications such as vision loss.
Treatment
Treatment for polymyalgia rheumatica is generally highly effective and is based primarily on the use of corticosteroids (glucocorticoids):
Corticosteroid Therapy
Prednisone or prednisolone is the first-line treatment. Therapy typically begins at a moderate dose (12.5 to 25 mg per day) and is gradually tapered over months to years. Most patients experience significant symptom relief within a few days of starting treatment, which is also diagnostically informative.
Long-Term Management
- The duration of treatment is usually 1 to 2 years, and sometimes longer.
- Regular monitoring of inflammatory markers and clinical assessments are necessary throughout treatment.
- In the event of a relapse, the corticosteroid dose is temporarily increased again.
- To prevent corticosteroid-related side effects such as osteoporosis, calcium and vitamin D supplementation and, if needed, bisphosphonates are recommended.
Biologic Therapy as an Alternative
For patients who cannot tolerate corticosteroids or experience frequent relapses, tocilizumab (an interleukin-6 receptor antagonist) may be considered as an alternative. This biologic agent has been approved for giant cell arteritis since 2017 and is used in select PMR cases as well.
Prognosis
The prognosis for polymyalgia rheumatica is generally favorable. With appropriate treatment, symptoms can be well controlled, and many patients are able to discontinue corticosteroid therapy after 1 to 2 years. However, relapses are possible and may require renewed or extended treatment. Regular medical follow-up is therefore essential to detect relapses early and prevent complications.
References
- Dejaco C, Singh YP, Perel P et al. - 2015 Recommendations for the Management of Polymyalgia Rheumatica. Arthritis and Rheumatology, 2015.
- Hellmich B, Agueda A, Monti S et al. - 2018 Update of the EULAR Recommendations for the Management of Large Vessel Vasculitis. Annals of the Rheumatic Diseases, 2020.
- Muratore F, Pazzola G, Pipitone N, Salvarani C - Recent advances in the diagnosis and treatment of polymyalgia rheumatica. Expert Review of Clinical Immunology, 2018.
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