Questionnaire/history:

> 50 years (most > 60)?

≥ 2 weeks of core symptoms:

- Bilateral shoulder and/or pelvic girdle pain & stiffness AND

- Stiffness lasting > 45 minutes after waking or periods of rest

Additional systemic symptoms (in 40-50%):

- Low-grade fever?

- Fatigue?

- Weight loss?

- Anorexia?

- Depression?

Past medical history?

Current medication?

Know drug allergies?

Investigations:

Bloods (FBC, ESR/CRP, U&E, LFT, Ca, CK, TSH, protein electrophoresis, rheumatoid factor)?

Urine dipstick?

Consider (depending on clinical features): ANA, anti-CCP antibodies, CXR, urine BJP

Differential diagnoses:

Giant cell arteritis (present in 15-20% of people with PMR)

Infections (viral, TB, osteomyelitis, infective endocarditis)

Cancer (myeloma, leukaemia, lymphoma, lung carcinoma)

Endocrine disease (thyroid or parathyroid disease)

Other inflammatory diseases (RA, SLE)

Degenerative conditions (OA or bilateral impingement/frozen shoulder)

Others (myositis/myalgia from statins, vit D deficiency, fibromyalgia, CFS)

Management:

If PMR most likely diagnosis:

Prednisolone 15 mg daily and review at 1 week (expect ≥ 70% improvement in symptoms within 1 week (typically many symptoms resolve within 24-72 hours))

If lesser response, consider increasing dose to 20mg, but if response still <70% refer

Note: PMR diagnosis can be confirmed if core symptoms present, other ‘mimic’ conditions excluded and there is a typical response to oral corticosteroids; ESR/CRP are typically raised but a diagnosis can be made if normal (but these patients need referring, see below)

Refer if:

Atypical features of PMR

Concern about alternative diagnosis:

- Red flags eg weight loss, night pain, neurological features

- Younger than 60 years old

- Chronic onset of symptoms

- Normal inflammatory markers or ESR >100 +/- very high CRP

- < 70% symptom response to 15-20 mg prednisolone daily

Information for patient/carer(s):

NHS Health A to Z: Polymyalgia

Versus Arthritis: Was is polymyalgia rheumatica?