Polymyalgia Rheumatica

An inflammatory condition causing shoulder ± hip girdle pain from low-grade synovitis. Morning stiffness lasting >45 minutes is the hallmark, with stiffness/pain improved by activity and worsened by rest — difficulty rolling over or getting out of bed. Associated with giant cell arteritis (GCA) — ~15% of PMR patients develop GCA. Overdiagnosed, particularly in patients <50 (almost always something else in that age group). See also rheumatology for the GCA-specific workup.

• Demographics: age >50 (typically 60–70); women > men; incidence rises with age.
• History: bilateral, symmetrical shoulder and pelvic-girdle aching; morning stiffness >45 min; no involvement of other joints.
• Examination: painful restriction of shoulder/hip range of motion.

Investigations

No specific diagnostic test — clinical presentation + elevated ESR/CRP.

• ~20% have a normal ESR at presentation; a persistently normal ESR suggests an alternative diagnosis. If early in the illness, retest ESR in 1–2 weeks.
• Check rheumatoid factor and anti-CCP antibody — should be negative (differential: polymyalgic-onset RA).
• Monitor ESR/CRP monthly for the first 3 months, then 3-monthly — don’t use in isolation, monitor symptoms too. A slight rise is normal when tapering steroids.

Management

Long corticosteroid course, typically ≥12 months — avoid tapering regimens under 9 months; don’t reduce the dose during an active flare.

Example taper (British Society of Rheumatology regimen): prednisolone 15 mg daily × 3 weeks → 12.5 mg × 3 weeks → 10 mg × 4–6 weeks → reduce by 1 mg every 4–8 weeks thereafter.

• Refer to rheumatology if steroids continue beyond 18 months, or for poor response.
• Methotrexate can be added as a steroid-sparing agent for patients not tolerating dose reduction, or relapsing on steroids (e.g. 10–25 mg weekly + folic acid 5 mg on non-dosing days).
• Encourage gentle, gradually-increasing exercise.

Emerging biologic option: sarilumab

Sarilumab (an IL-6 receptor inhibitor) was FDA-approved February 2023 as the first biologic treatment for PMR, for patients relapsing on ≥7.5 mg/day prednisolone during taper — it substantially cuts cumulative corticosteroid exposure (SAPHYR trial: median 777 mg vs 2044 mg over 52 weeks). Tocilizumab has also shown benefit in glucocorticoid-dependent PMR. Australian TGA/PBS availability for either drug in PMR is not confirmed — check current status before considering.