Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is a common inflammatory condition characterised by aching and stiffness in the shoulder girdle, neck, upper arms, hip girdle and thighs. It predominantly affects people over the age of 50, with peak onset between 70 and 80 years, and is approximately twice as common in women. It is one of the most common inflammatory rheumatic conditions in older adults, with a lifetime risk of approximately 2% in women and 1% in men.

The underlying pathology involves inflammation of the bursae around the shoulder and hip joints, with large vessel vasculitis in some cases. PMR is closely related to giant cell arteritis (GCA) — a vasculitis affecting large and medium-sized vessels — and around 15–20% of patients with PMR will have concurrent GCA. Any patient with PMR who develops headache, scalp tenderness, jaw claudication or visual symptoms requires urgent evaluation to exclude GCA.

The condition typically responds dramatically to corticosteroids — often within days — and this response is itself a diagnostic feature. However, long-term corticosteroid therapy carries significant risks, including osteoporosis, diabetes, hypertension, weight gain and adrenal suppression. Careful steroid tapering under specialist supervision, combined with bone protection and cardiovascular risk management, is therefore essential.

Corticosteroids are the mainstay of treatment for PMR and usually produce a dramatic and rapid response. Prednisolone is typically started at 15–25mg daily and gradually tapered over 12–24 months according to symptoms and inflammatory markers. The dramatic improvement in symptoms within 24–72 hours is both therapeutically important and diagnostically useful — a slow or poor response to corticosteroids should prompt reassessment of the diagnosis.

Bone protection with calcium, vitamin D and a bisphosphonate should be initiated at the outset of corticosteroid therapy. Blood pressure and glucose monitoring are important, as steroids can elevate both. The aim of steroid tapering is to use the lowest effective dose for the shortest necessary period. Relapses are common during or after steroid reduction and may require temporary dose increases.

For patients who relapse frequently or cannot tolerate adequate steroid tapering, tocilizumab — an IL-6 receptor inhibitor — is licensed as a steroid-sparing agent for PMR and has demonstrated the ability to reduce total corticosteroid exposure and relapse rates. Other immunosuppressive agents such as methotrexate may also be considered. Regular monitoring of disease activity, steroid side effects and bone health is an integral part of long-term management.