What is polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory disorder that causes of widespread aching and stiffness in your neck, shoulders, and hips that affects adults over the age of 65-70, especially Caucasians, but all races can get polymyalgia rheumatica. Polymyalgia rheumatica is rarely seen in people younger than 50. Because polymyalgia rheumatica does not often cause swollen joints, it may be hard to recognize. The main symptom of polymyalgia rheumatica is stiffness after resting. Other symptoms include fever, weakness and weight loss. In some cases, polymyalgia rheumatica develops overnight. In others, polymyalgia rheumatica symptoms come on over a few days or weeks. Both sides of the body are equally affected. Involvement of the upper arms, with trouble raising them above your shoulders, is common. Sometimes, aching occurs at joints such as the hands and wrists.

Recent research suggests that inflammation in polymyalgia rheumatica involves the shoulder and hip joints themselves, and the bursae (or sacs) around these joints. So pains at the upper arms and thighs, in fact, start at the nearby shoulder and hip joints. This is what doctors call “referred pain.”

Polymyalgia rheumatica should not be confused with fibromyalgia, a poorly understood syndrome that unlike polymyalgia rheumatica has no evidence of inflammation.

Polymyalgia rheumatica occurs at the rate of about 50 per 100,000 in people over 50 years of age. Polymyalgia rheumatica is estimated to affect 450,000 individuals in the United States.

Polymyalgia rheumatica is a self-limiting condition, with treatment, polymyalgia rheumatica usually disappears in a day or two. Without treatment, polymyalgia rheumatica usually goes away after a year to five years; however, it varies from person to person. Approximately 15 percent of people with polymyalgia rheumatica develop a potentially dangerous condition called giant cell arteritis (also known as temporal arteritis), a condition that causes swelling of the arteries in your head. Symptoms include headaches and blurred vision. Doctors often prescribe prednisone, a steroid medicine, for both giant cell arteritis and polymyalgia rheumatica.

The average age when polymyalgia rheumatica symptoms start is 65-70, so people who have polymyalgia rheumatica may be in their 80s or even older. Polymyalgia rheumatica affects women somewhat more often than men.

Achiness is always worse in the morning and improves as the day goes by. Yet inactivity, such as a long car ride or sitting too long in one position, may cause stiffness to return.

Stiffness may be so severe that it causes any of these problems:

• Disturbed sleep
• Trouble getting dressed in the morning (for instance, putting on a jacket or bending over to pull on socks and shoes)
• Problems getting up from a sofa or in and out of a car

The cause of polymyalgia rheumatica is not known. There is no single test to diagnose polymyalgia rheumatica. Your doctor will use your medical history, symptoms, and a physical exam to make the diagnosis. Lab tests for inflammation may help confirm the diagnosis.

Is there a cure for polymyalgia rheumatica?

There is no “cure” as such for polymyalgia rheumatica, but corticosteroid medication called prednisolone can help control inflammation and relieve your symptoms. Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It doesn’t cure polymyalgia rheumatica, but it can help relieve the symptoms. Most people with polymyalgia rheumatica will need to take a course of corticosteroid treatment that lasts 18 months to two years to prevent their symptoms returning.

Polymyalgia rheumatica is a self-limiting condition, with treatment, polymyalgia rheumatica usually disappears in a day or two. Without treatment, polymyalgia rheumatica usually goes away after a year to five years, however, this can vary between individuals.

Polymyalgia rheumatica prognosis

Polymyalgia rheumatica has an excellent prognosis with prompt diagnosis and adequate therapy.

The good news is that the symptoms of polymyalgia rheumatica usually improve with treatment. In fact, most people find their symptoms improve dramatically within a few days of starting corticosteroid medication treatment. It usually takes two to three years for polymyalgia rheumatica to settle completely. Most people will need to continue treatment during this time to keep the symptoms under control. Polymyalgia rheumatica can return, particularly when you stop treatment, however this is rare if you have been free of symptoms for some time.

Polymyalgia rheumatica complications

Symptoms of polymyalgia rheumatica can greatly affect your ability to perform everyday activities. The pain and stiffness may contribute to difficulties with tasks such as the following:

• Getting out of bed, standing up from a chair or getting out of a car
• Bathing or combing your hair
• Getting dressed or putting on a coat

These difficulties can affect your health, social interactions, physical activity, sleep and general well-being.

In addition, people with polymyalgia rheumatica seem to be more likely to develop peripheral arterial disease.

Polymyalgia rheumatica causes

The cause of polymyalgia rheumatica is unknown, but it is believed to be an autoimmune disease in which the body’s own immune system attacks the connective tissues. Polymyalgia rheumatica does not result from side effects of medications. The abrupt onset of symptoms suggests the possibility of an infection but, so far, none has been found. “Myalgia” comes from the Greek word for “muscle pain.” However, specific tests of the muscles, such as a blood test for muscle enzymes or a muscle biopsy (surgical removal of a small piece of muscle for inspection under a microscope), are all normal.

Polymyalgia rheumatica has a modest familial aggregation and is linked to the HLA DR4 allele in Caucasian populations. Epigenetic changes and differential expression of genes that regulate the expression of inflammatory cytokines probably account for the variability in disease phenotypes ¹.

Two factors appear to be involved in the development of polymyalgia rheumatica:

• Genetics. Certain genes and gene variations may increase your susceptibility.
• An environmental exposure. New cases of polymyalgia rheumatica tend to come in cycles and may develop seasonally. This suggests that an environmental trigger, such as a virus, might play a role. But no specific virus has been shown to cause polymyalgia rheumatica.

Because polymyalgia rheumatica is rare in people under age 50, its cause could be linked to the aging process.

Giant cell arteritis

Polymyalgia rheumatica and another disease known as giant cell arteritis share many similarities. Giant cell arteritis results in inflammation in the lining of arteries, most often the arteries located in the temples. Giant cell arteritis can cause headaches, jaw pain, vision problems and scalp tenderness. If left untreated, it can lead to stroke or blindness.

Polymyalgia rheumatica and giant cell arteritis may actually be the same disease but with different manifestations. The overlap between the two diseases is significant:

• About 20 percent of people with polymyalgia rheumatica also have signs and symptoms of giant cell arteritis.
• About half of the people with giant cell arteritis may also have polymyalgia rheumatica.

Despite the similarities in age of onset and some of the clinical manifestations, the relationship between giant cell arteritis and polymyalgia rheumatica is not yet clearly established ².

Risk factors for polymyalgia rheumatica

Risk factors for polymyalgia rheumatica include:

• Age. Polymyalgia rheumatica affects older adults almost exclusively. The average age at onset of the disease is 73.
• Sex. Women are about two times more likely to develop the disorder.
• Race and geographic region. Polymyalgia rheumatica is most common among whites in northern European populations.

Polymyalgia rheumatica vs Fibromyalgia

Polymyalgia, or polymyalgia rheumatica, is an inflammatory disease of muscle. The cause is uncertain but it is believed to be an autoimmune disease in which the body’s own immune system attacks the connective tissues. The primary symptoms are severe stiffness and pain in the muscles of the neck, shoulder and hip areas. People with this condition also may have flu like symptoms, including fever, weakness and weight loss, and approximately 15 percent develop a potentially dangerous condition called giant cell arteritis – an inflammation of the arteries that supply the head.

Fibromyalgia is a common neurologic health problem that causes widespread pain and tenderness (sensitivity to touch) all over the body and other symptoms. Research suggests fibromyalgia is not an autoimmune, inflammation, joint, or muscle based illness, but an abnormal sensory processing in the central nervous system (brain and spinal cord) is involved. There is most often some triggering factor that sets off fibromyalgia. It may be spine problems, arthritis, injury, or other type of physical stress. Emotional stress also may trigger fibromyalgia. The result is a change in the way the body “talks” with the spinal cord and brain. Levels of brain chemicals and proteins may change. More recently, fibromyalgia has been described as Central Pain Amplification disorder, meaning the volume of pain sensation in the brain is turned up too high.

Fibromyalgia is most common in women, though it can occur in men. Fibromyalgia most often starts in middle adulthood, but can occur in the teen years and in old age. You are at higher risk for fibromyalgia if you have a rheumatic disease (health problem that affects the joints, muscles and bones). These include osteoarthritis, lupus, rheumatoid arthritis, or ankylosing spondylitis.

Fibromyalgia pain and tenderness tend to come and go, and move about the body. Most often, people with this chronic (long-term) illness are fatigued (very tired), have sleep problems and trouble concentrating with irritable bowel syndrome and headaches. The diagnosis can be made with a careful examination.

Fibromyalgia tends to be chronic, often lasting a lifetime, whereas polymyalgia rheumatica usually resolves itself within two years.

Fibromyalgia may run in families. There likely are certain genes that can make people more prone to getting fibromyalgia and the other health problems that can occur with it. Genes alone, though, do not cause fibromyalgia.

Fibromyalgia symptoms

Fibromyalgia, also called fibromyalgia syndrome, is a long-term condition that causes pain all over the body.

As well as widespread pain, people with fibromyalgia may also have:

• Tenderness to touch or pressure affecting muscles and sometimes joints or even the skin
• Severe fatigue (extreme tiredness)
• Sleep problems (waking up unrefreshed)
• Muscle stiffness
• Problems with memory or thinking clearly (known as “fibro-fog”) – such as problems with memory and concentration

Some patients also may have:

• Depression or anxiety
• Migraine or tension headaches
• Digestive problems: irritable bowel syndrome (commonly called IBS) or gastroesophageal reflux disease (often referred to as GERD)
• Irritable or overactive bladder
• Pelvic pain
• Temporomandibular disorder – often called TMJ (a set of symptoms including face or jaw pain, jaw clicking, and ringing in the ears)
• Headaches

Although fibromyalgia can affect quality of life, it is still considered medically benign. Fibromyalgia does not cause any heart attacks, stroke, cancer, physical deformities, or loss of life.

Fibromyalgia diagnosis

Criteria Needed for a Fibromyalgia Diagnosis ³

1. Pain and symptoms over the past week, based on the total of number of painful areas out of 19 parts of the body plus level of severity of these symptoms:
   • a. Fatigue
   • b. Waking unrefreshed
   • c. Cognitive (memory or thought) problems
   • Plus number of other general physical symptoms
2. Symptoms lasting at least three months at a similar level
3. No other health problem that would explain the pain and other symptoms

Fibromyalgia treatment

There is no cure for fibromyalgia. However, symptoms can be treated with both non-drug and medication based treatments. Many times the best outcomes are achieved by using multiple types of treatments.

Fibromyalgia is treated with exercise, relaxation techniques, analgesic medications and antidepressants to relieve pain and promote sleep.

Non-Drug Therapies

People with fibromyalgia should use non-drug treatments as well as any medicines their doctors suggest. Research shows that the most effective treatment for fibromyalgia is physical exercise. Physical exercise should be used in addition to any drug treatment. Patients benefit most from regular aerobic exercises. Other body-based therapies, including Tai Chi and yoga, can ease fibromyalgia symptoms. Although you may be in pain, low impact physical exercise will not be harmful.

Cognitive behavioral therapy is a type of therapy focused on understanding how thoughts and behaviors affect pain and other symptoms. CBT and related treatments, such as mindfulness, can help patients learn symptom reduction skills that lessen pain. Mindfulness is a non-spiritual meditation practice that cultivates present moment awareness. Mindfulness based stress reduction has been shown to significantly improve symptoms of fibromyalgia.

Other complementary and alternative therapies (sometimes called CAM or integrative medicine), such as acupuncture, chiropractic and massage therapy, can be useful to manage fibromyalgia symptoms. Many of these treatments, though, have not been well tested in patients with fibromyalgia.

It is important to address risk factors and triggers for fibromyalgia including sleep disorders, such as sleep apnea, and mood problems such as stress, anxiety, panic disorder, and depression. This may require involvement of other specialists such as a Sleep Medicine doctor, Psychiatrist, and therapist.

Medications

The U.S. Food and Drug Administration has approved three drugs for the treatment of fibromyalgia. They include two drugs that change some of the brain chemicals (serotonin and norepinephrine) that help control pain levels: duloxetine (Cymbalta) and milnacipran (Savella). Older drugs that affect these same brain chemicals also may be used to treat fibromyalgia. These include amitriptyline (Elavil) and cyclobenzaprine (Flexeril). Other antidepressant drugs can be helpful in some patients. Side effects vary by the drug. Ask your doctor about the risks and benefits of your medicine.

The other drug approved for fibromyalgia is pregabalin (Lyrica). Pregabalin and another drug, gabapentin (Neurontin), work by blocking the over activity of nerve cells involved in pain transmission. These medicines may cause dizziness, sleepiness, swelling and weight gain.

It is strongly recommended to avoid opioid narcotic medications for treating fibromyalgia. The reason for this is that research evidence shows these drugs are not of helpful to most people with fibromyalgia, and will cause greater pain sensitivity or make pain persist. Tramadol (Ultram) may be used to treat fibromyalgia pain if short-term use of an opioid narcotic is needed. Over-the-counter medicines such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (commonly called NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox) are not effective for fibromyalgia pain. Yet, these drugs may be useful to treat the pain triggers of fibromyalgia. Thus, they are most useful in people who have other causes for pain such as arthritis in addition to fibromyalgia.

For sleep problems, some of the medicines that treat pain also improve sleep. These include cyclobenzaprine (Flexeril), amitriptyline (Elavil), gabapentin (Neurontin) or pregabalin (Lyrica). It is not recommended that patients with fibromyalgia take sleeping medicines like zolpidem (Ambien) or benzodiazepine medications.

Living with fibromyalgia

Even with the many treatment options, patient self-care is vital to improving symptoms and daily function. In concert with medical treatment, healthy lifestyle behaviors can reduce pain, increase sleep quality, lessen fatigue and help you cope better with fibromyalgia. With proper treatment and self-care, you can get better and live a more normal life. Here are some self-care tips for living with fibromyalgia:

• Make time to relax each day. Deep-breathing exercises and meditation will help reduce the stress that can bring on symptoms.
• Set a regular sleep pattern. Go to bed and wake up at the same time each day. Getting enough sleep lets your body repair itself, physically and mentally. Also, avoid daytime napping and limit caffeine intake, which can disrupt sleep. Nicotine is a stimulant, so those fibromyalgia patients with sleep problems should stop smoking.
• Exercise often. This is a very important part of fibromyalgia treatment. While difficult at first, regular exercise often reduces pain symptoms and fatigue. Patients should follow the saying, “Start low, go slow.” Slowly add daily fitness into your routine. For instance, take the stairs instead of the elevator, or park further away from the store. As your symptoms decrease with drug treatments, start increasing your activity. Add in some walking, swimming, water aerobics and/or stretching exercises, and begin to do things that you stopped doing because of your pain and other symptoms. It takes time to create a comfortable routine. Just get moving, stay active and don’t give up!
• Educate yourself. Nationally recognized organizations like the Arthritis Foundation (https://www.arthritis.org/) and the National Fibromyalgia Association (http://www.fmaware.org/) are great resources for information. Share this information with family, friends and co-workers.
• Look forward, not backward. Focus on what you need to do to get better, not what caused your illness.

Polymyalgia rheumatica symptoms

The symptoms of polymyalgia rheumatica result from inflammation of the joints and surrounding tissues. Symptoms make start slowly or suddenly. Stiffness is usually worse in the morning and during long periods of inactivity. Sometimes, pain and stiffness can lead to lack of use of some body parts, which could result in weakness.

Most people with polymyalgia rheumatica have pain and stiffness on both sides of the body and in at least two of the following areas:

• Aches or pain in your shoulders (often the first symptom)
• Aches or pain in your neck, upper arms, buttocks, hips or thighs
• Stiffness in affected areas, particularly in the morning or after being inactive for a long time
• Limited range of motion in affected areas
• Pain or stiffness in your wrists, elbows or knees (less common)

You may also have more general signs and symptoms, including:

• Mild fever
• Fatigue
• A general feeling of not being well (malaise)
• Loss of appetite
• Unintended weight loss
• Depression

Polymyalgia rheumatica may also occur with another serious condition called giant cell arteritis (also known as temporal arteritis), which can be dangerous. Headaches — particularly on the side of the head — scalp tenderness, vision changes or jaw pain when eating can be signs of this condition.

Polymyalgia rheumatica diagnosis

Polymyalgia rheumatica can be hard to diagnose. Studies show that 2 to 30 percent of people initially given a diagnosis of polymyalgia rheumatica were later reclassified as having rheumatoid arthritis.

Your answers to questions, a general physical exam and the results of tests can help your doctor determine the cause of your pain and stiffness. This diagnostic process also helps your doctor rule out other disorders that have similar symptoms to polymyalgia rheumatica.

If your doctor strongly suspects polymyalgia rheumatica, you will receive a trial of low-dose corticosteroids. Often, the dose is 10–15 milligrams per day of prednisone (Deltasone, Orasone, etc.). If polymyalgia rheumatica is present, the medicine quickly relieves stiffness. The response to corticosteroids can be dramatic. Sometimes patients are better after only one dose. Improvement can be slower, though. But, if symptoms do not go away after two or three weeks of treatment, the diagnosis of polymyalgia rheumatica is not likely, and your doctor will consider other causes of your illness. Your doctor may reassess your diagnosis as your treatment progresses.

Physical exam

Your doctor will conduct an exam to get an idea of your overall health, identify possible causes or rule out certain diseases. He or she may gently move your head and limbs to assess whether your symptoms affect your range of motion.

Blood tests

A sample of your blood will be used for several laboratory tests that your doctor will order. Typically, your doctor will check the complete blood counts (CBC) and two indicators of inflammation — erythrocyte sedimentation rate (ESR, also called sed rate) and C-reactive protein (CRP).

If the ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) test results are normal, it’s unlikely that polymyalgia rheumatica will be diagnosed.

Sometimes the ESR may be normal and the CRP may be raised, which would be more likely to indicate a positive diagnosis. This is why both tests are usually carried out at the same time.

As inflammation is a feature of many conditions, high levels don’t automatically mean you have polymyalgia rheumatica.

Further tests may be needed to help rule out other conditions that cause inflammation. For example, a test for rheumatoid factor and anti-CCP antibodies may be carried out to rule out rheumatoid arthritis.

Blood tests may include:

• Anticyclic citrullinated peptide (anti-CCP)
• Antinuclear antibody (ANA)
• Complete blood count (CBC)
• Rheumatoid factor (RF)

These blood tests will be done to check inflammation levels and to rule out conditions that cause symptoms similar to polymyalgia rheumatica, such as rheumatoid arthritis and lupus.

You may also have a urine test to check how well your kidneys are functioning.

X-rays and ultrasound scans may also be used to look at the condition of your bones and joints.

Imaging tests

Increasingly, ultrasound is being used to distinguish polymyalgia rheumatica from other conditions that cause similar symptoms. Magnetic resonance imaging (MRI) can also identify other causes of shoulder pain, such degenerative joint changes.

Monitoring for giant cell arteritis

Your doctor will monitor you for signs and symptoms that may indicate the onset of giant cell arteritis. Talk to your doctor immediately if you experience any of the following:

• New, unusual or persistent headaches
• Jaw pain or tenderness
• Blurred or double vision or visual loss
• Scalp tenderness

American College of Rheumatology diagnostic criteria for giant cell arteritis (temporal arteritis) ⁴

• Age >50 years
• New onset of localised headache
• Temporal artery tenderness or decreased temporal artery pulse
• ESR ≥50 mm/hr
• Positive temporal artery biopsy

If your doctor suspects you may have giant cell arteritis, he or she will likely order a biopsy of the artery in one of your temples. This procedure, performed during local anesthesia, removes a tiny sample of the artery, which is then examined in a laboratory for signs of inflammation.

Polymyalgia rheumatica symptom checklist

After other possible causes of your symptoms have been ruled out, a checklist can be used to see whether your symptoms match those most commonly associated with polymyalgia rheumatica.

A confident diagnosis of polymyalgia rheumatica can usually be made if you meet all of the following criteria:

• you’re over 50 years of age
• you have pain in your shoulders or your hips
• you have stiffness in the morning that lasts longer than 45 minutes
• your symptoms have lasted for more than two weeks
• blood tests show raised levels of inflammation in your body
• your symptoms rapidly improve after treatment with corticosteroids

New diagnostic criteria for polymyalgia rheumatica

In 2012 the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) established a working party to seek expert opinion and analyze all previously published criteria to produce a list of potential discriminating variables. They conducted a 6-month prospective cohort study that included a cohort of patients with new-onset polymyalgia rheumatica and a comparison cohort of non-polymyalgia rheumatica patients with various conditions that mimic polymyalgia rheumatica. Patients with and without polymyalgia rheumatica underwent ultrasound evaluation of shoulders and hips.

Key differences between the existing British Society for Rheumatology (BSR) criteria and the new EULAR/ACR criteria include the absence of response to steroid treatment (this was not found to have sufficient discriminating value to be included) and the addition of shoulder and hip abnormalities on ultrasound (Table 1) ⁵. The EULAR/ACR criteria are classification criteria primarily intended to select patients with definite disease for inclusion in clinical trials and thus sacrifice sensitivity for specificity. Nevertheless, they still have valuable diagnostic utility. In addition, these criteria may be applied only to those patients in whom the symptoms are not better explained by an alternative diagnosis.

Table 1. Classification criteria for polymyalgia rheumatica

BSR and BHPR guidelines (2009) 6	New EULAR/ACR classification (2012) 5
Age >50 years, duration >2 weeks	Age ≥50 years with new bilateral shoulder pain
Bilateral shoulder or pelvic girdle aching, or both	New hip involvement (pain, tenderness, limited movement)
Morning stiffness for >45 min	Morning stiffness for >45 min
Evidence of an acute-phase response	Elevated C-reactive protein and/or ESR
Normal inflammatory markers if there is a classical clinical picture and response to steroids	In the absence of peripheral synovitis or of positive RA serology
	Ultrasound findings of bilateral shoulder abnormalities (subacromial bursitis, bicipital tenosynovitis, glenohumeral effusion) or abnormalities in one shoulder and hip (hip effusion, trochanteric bursitis)

Note: BSR = British Society for Rheumatology; BHPR = British Health Professionals in Rheumatology; EULAR = European League Against Rheumatism; ACR = American College of Rheumatology

Table 2. Conditions that can mimic polymyalgia rheumatica

Inflammatory disorders	Clinical features
Rheumatoid arthritis	Mainly distal joint symptoms; may be positive for RF and anti-CCP; erosive joint disease on radiography
Late-onset spondyloarthropathy, including ankylosing spondylitis, psoriatic arthritis	Predominantly low back stiffness and pain; may have large and distal joint symptoms; spinal ankylosis on radiography; psoriasis
Remitting seronegative symmetric synovitis with pitting oedema (RS3PE) syndrome	Peripheral hand or foot oedema
Systemic lupus erythematous, scleroderma, Sjögren’s syndrome, vasculitis	Fatigue, stiffness, multisystem disease, presence of antinuclear antibodies and anti-neutrophil cytoplasmic antibodies
Dermatomyositis, polymyositis	Proximal muscle weakness, rash: creatine kinase raised
Non-Inflammatory disorders
Osteoarthritis, spinal spondylosis	Articular pain of shoulder, neck and hip joints; gelling; degenerative changes on radiography
Rotator cuff disease, adhesive capsulitis (frozen shoulder)	Periarticular pain, restricted range of motion; ultrasound and magnetic resonance imaging may show characteristic bursa and synovial inflammation
Infections, including viral syndromes, osteomyelitis, bacterial endocarditis, tuberculosis	Fever, weight loss, heart murmur, deep soft tissue and bone pain, microscopic haematuria
Chronic pain syndromes, fibromyalgia, depression	Fatigue, longstanding pain, tender points, sadness, loss of usual interests
Endocrine and metabolic diseases, such as thyroid and parathyroid disorders and osteomalacia	Bone pain, fatigue; abnormalities of thyroid and parathyroid hormone, calcium, phosphorus, vitamin D concentrations

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Polymyalgia rheumatica treatment

Treatment usually involves medications to help ease your symptoms. Relapses are common.

Nonsteroidal anti-inflammatory drugs (commonly called NSAIDs), such as ibuprofen, (Advil, Motrin, etc.) and naproxen (Naprosyn, Aleve) are not effective in treating polymyalgia rheumatica. However, your doctor may these painkillers, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), to help relieve your pain and stiffness while your dose of prednisolone is reduced.

Corticosteroids

Polymyalgia rheumatica is usually treated with a low dose of an oral corticosteroid, such as prednisone. A daily dose at the beginning of treatment is usually 12 to 25 milligrams a day.

You’ll likely start to feel relief from pain and stiffness within the first two or three days. If you aren’t responding to treatment, your doctor may refer you to a rheumatologist.

After the first two to four weeks of treatment, your doctor may begin to gradually decrease your dosage depending on your symptoms and the results of blood tests. The goal is to keep you on as low a dose as possible without triggering a relapse in your symptoms. Because the symptoms of polymyalgia rheumatica are sensitive to even small changes in the dose of corticosteroids, your doctor should direct the gradual decrease of this medicine.

Most people with polymyalgia rheumatica need to continue the corticosteroid treatment for at least a year. Others, though, will need a small amount of this corticosteroids for 2–3 years, to keep aching and stiffness under control. Symptoms can recur. You’ll need frequent follow-up visits with your doctor to monitor how the treatment is working and whether you’re having any side effects.

People who taper off the medication too quickly are more likely to have a relapse. Thirty to 60 percent of people with polymyalgia rheumatica will have at least one relapse when tapering off the corticosteroids. Relapses (flares) are treated by increasing your drug dosage for a while then tapering again.

Table 3. BSR/BHPR prednisolone-tapering regimen for giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis	Polymyalgia rheumatica
Prednisolone 40–60mg (not <0.75 mg/kg) continued for 4 weeks (until resolution of symptoms and laboratory abnormalities)	Prednisolone 15 mg for 3 weeks
Reduction by 10 mg every 2 weeks to 20 mg	12.5 mg for 3 weeks
Reduction by 2.5 mg every 2–4 weeks to 10 mg	10 mg for 4–6 weeks
Reduction by 1 mg every 1–2 months provided there is no relapse	Reduction by 1 mg every 4–8 weeks or alternate day reductions (eg. 10/7.5 mg alternate days)

Note: BSR = British Society for Rheumatology; BHPR = British Health Professionals in Rheumatology
[Source ⁶, ⁸]

How prednisolone works

Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It doesn’t cure polymyalgia rheumatica, but it can help relieve the symptoms.

When used to treat polymyalgia rheumatica, prednisolone is taken as a tablet. Most people will be prescribed several tablets to take once a day.

You’ll be prescribed a high dose of prednisolone to start with, and the dose will be gradually reduced every one to two months.

Although your symptoms should improve within a few days of starting treatment, you’ll probably need to continue taking a low dose of prednisolone for about two years.

In many cases, polymyalgia rheumatica improves on its own after this time. However, there’s a chance it will return after treatment stops, known as a relapse.

Don’t suddenly stop taking steroid medication unless your doctor tells you it’s safe to do so. Suddenly stopping treatment with steroids can make you very ill.
Side effects of prednisolone

About 1 in 20 people who take prednisolone will experience changes in their mental state when they take the medication.

You may feel depressed and suicidal, anxious or confused. Some people also experience hallucinations, which is seeing or hearing things that aren’t there.

Contact your doctor as soon as possible if you experience changes to your mental state.

Other side effects of prednisolone include:

• increased appetite, which often leads to weight gain
• increased blood pressure
• mood changes, such as becoming aggressive or irritable with people
• weakening of the bones (osteoporosis)
• stomach ulcers
• increased risk of infection, particularly with the varicella-zoster virus, the virus that causes chickenpox and shingles

You should seek immediate medical advice if you think you’ve been exposed to the varicella-zoster virus or if a member of your household develops chickenpox or shingles.

The risk of these side effects should improve as your dose of prednisolone is decreased.

Monitoring side effects

Long-term use of corticosteroids can result in a number of serious side effects. Your doctor will monitor you closely for problems. He or she may adjust your dosage and prescribe treatments to manage these reactions to corticosteroid treatment. Possible side effects include:

• Weight gain
• Osteoporosis — the loss of bone density and weakening of bones
• High blood pressure (hypertension)
• Diabetes
• Thinning of the skin and bruising
• Cataracts — a clouding of the lenses of your eyes

It is recommended that clinicians assess bone mineral density (BMD) before initiating corticosteroid treatment, which is likely to last longer than 3 months. The following steps should be taken at the commencement of steroid therapy ⁹:

• Start adequate supplementation of calcium (1200 mg/day) and vitamin D3 (cholecalciferol, 800 IU/day)
• Assess lumber and hip spine bone mineral density
• If bone mineral density T-score is –1.5 or less consider an oral bisphosphonate such as alendronate (70 mg/week) or risedronate sodium (35 mg/week).

Calcium and vitamin D supplements

Your doctor will likely prescribe daily doses of calcium and vitamin D supplements to help prevent bone loss induced by corticosteroid treatment. The American Academy of Rheumatology recommends the following daily doses for anyone taking corticosteroids:

• 1,200 to 1,500 milligrams (mg) of calcium supplements
• 800 to 1,000 international units (IU) of vitamin D supplements

Pneumonia vaccine

Your doctor may suggest you get a pneumonia vaccine if you are taking 20 milligrams or more of prednisone a day.

Methotrexate (Trexall)

Some people are prescribed immunosuppressant medication, such as methotrexate. This is used to suppress the immune system, the body’s defence against infection and illness. It may help people with polymyalgia rheumatica who have frequent relapses or don’t respond to normal steroid treatment.

Joint guidelines from the American Academy of Rheumatology and the European League Against Rheumatism suggest using methotrexate with corticosteroids in some patients. This is an immune-suppressing medication that is taken by mouth. It may be useful early in the course of treatment or later, if you relapse or don’t respond to corticosteroids.

Physical therapy

You may benefit from physical therapy if you’ve had a long stretch of limited activity owing to polymyalgia rheumatica. Talk with your doctor about whether physical therapy is a good option for you if you’re trying to regain strength, coordination and the ability to perform everyday tasks.

Polymyalgia rheumatica diet

Eat a healthy diet. Eat a diet of fruits, vegetables, whole grains, and low-fat meat and dairy products. Limit the salt (sodium) in your diet to prevent fluid buildup and high blood pressure.

Home remedies

Over-the-counter nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve), are not usually recommended for easing the signs and symptoms of polymyalgia rheumatica.

Healthy lifestyle choices can help you manage the side effects that may result from corticosteroid treatment:

• Exercise regularly. Regular exercise is essential for maintaining joint flexibility, muscle strength and function. Good forms of exercise include walking, riding a stationary bicycle and exercising in a pool. Rest is also necessary to give the body time to recover from exercise and other activities. Talk to your doctor about exercise that is appropriate for you to maintain a healthy weight and to strengthen bones and muscles.
• Use assistive devices. Use luggage and grocery carts, reaching aids, shower grab bars and other assistive devices to help make daily tasks easier. Take steps to minimize the risk of falls, such as wearing low-heeled shoes. Talk to your doctor about whether the use of a cane or other walking aid is appropriate for you to prevent falls or other injury.

Polymyalgia rheumatica will eventually go away, but this may take up to five years. Proper nutrition, activity, rest and following medication regimens are important for managing the condition. Once stiffness goes away, a person can return to daily activities, including exercise, as tolerated.

Coping and support

Even though you’ll start to feel better soon after you begin treatment, it can be frustrating having to take medication daily, especially one that can cause such serious side effects. Ask your health care team what steps you can take to stay healthier while you’re taking corticosteroids. Your doctor may also know if there are any local support groups in your area. Talking to others who are living with the same illness and challenges can be helpful and encouraging.

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