Polymyalgia Rheumatica

General Overview

💡PMR is the most common inflammatory rheumatologic condition in the elderly (peak incidence at 70-80yo) and typically affects women (3 female:1 male).

  • Manifests with:

    • Age >50 yo

    • Musculoskeletal symptoms (lasting > 2 weeks):

      • Symmetric pain/aching and morning stiffness > 45 mins affecting shoulders/neck/hip

      • Stiffness relieved with activity

    • Systemic symptoms (fatigue, malaise, night sweats, depressed mood)

      • Fever should prompt to rule out inflammatory (GCA) or infectious pathology

    • Elevated ESR (more prognostic) and/or CRP (more sensitive)

    • Rapid improvement with low-dose systemic steroids (eg. 15-25mg/day prednisone)

  • Exclude non-inflammatory, inflammatory (such as giant cell arteritis or rheumatoid arthritis), drug, endocrine, infectious and malignancy

Red Flags (Features of Giant Cell Arteritis)

~20% associated with giant cell (temporal) arteritis

  • New sudden-onset headache

  • New sudden-onset visual changes

  • Upper cranial nerve palsies

  • Jaw/tongue claudication

  • Limb claudication or suggestion of large vessel involvement

  • Prominence, beading or diminished pulse of temporal artery

  • Temporal tenderness

  • Fever, anemia, constitutional symptoms/signs

Physical examination

  • Cardio

    • Assess bilateral BP discrepancy, temporal arteries swelling/tenderness/bruits (to detect GCA)

  • MSK

    • Decreased ROM of shoulders, neck, hips but preserved muscle strength

    • Muscle tenderness surrounding affected joints

  • Neuro

    • Normal muscle strength in PMR (despite subjective weakness or pain)


  • ↑ ESR, ↑ CRP

    • ESR elevation better correlated to severity but CRP more sensitive (99% Sn)

  • Rule out mimics:

    • ANA, RF, anti-CCP (SLE, rheumatoid arthritis)

    • CK (polymyositis/dermatomyositis)

    • CBC, SPEP/FLC, Calcium, ALP, Vitamin D (bony disease, eg. multiple myeloma)

    • TSH (hypothyroidism)

  • Other: LFT, UA


💡 Given risks of long-term corticosteroid use, consider baseline BMD and consider osteoporosis prophylaxis

  • Prednisone 15mg PO daily (can also be divided BID)

    • Response usually observed within three days

      • If no response after one week, consider increase to 20mg PO daily

        • If still no response, consider alternative diagnosis (most commonly RA)

    • Maintain effective steroid dose for 2-4 weeks until after symptoms resolve, then gradually taper every 2-4 weeks (example regimen:15mg x 2-4w → 12.5mg x 2-4w → 10mg x 2-4w → 9mg x 4-8w → 8mg x 4-8w → 7mg x 4-8w → etc.)

      • Can often take 1-2 years to fully taper off steroids!

  • Relapse is common (treat with previously effective dose), monitor for giant cell arteritis (temporal arteritis)

  • Refer to Rheumatology if atypical (e.g., age < 50, systemic symptoms, peripheral or asymmetric joint involvement, systemic symptoms, low ESR/CR, relapse or prolonged therapy)

Last edited 2021-08-04
B. Paul, K. Chan