Polymyalgia Rheumatica (PMR)
What is it?
It is common and disabling condition characterised by severe pain and stiffness.
What are the Symptoms?
The main symptoms are pain and stiffness, usually affecting the shoulders and characteristically worse in the morning. From being “normal” to having the full disability takes about two or three weeks. i.e. it is fairly rapid in onset, unlike arthritis and other inflammatory diseases which are gradual in onset.
How is it diagnosed?
Characteristically the patient with PMR has:
Shoulder pain, roughly the same on both sides
Morning stiffness that lasts at least 30 minutes
Raised levels of inflammation measured by blood tests
No disturbance or swelling in the small joints of the hands and feet.
Note that there is no single test to prove the diagnosis, but the symptoms, the physical findings and the blood tests are very, very characteristic. The patient is usually elderly (>60) and it is far more common in females.
How is it treated?
Primarily using steroids in the form of prednisolone. These small tablets are taken at 8 am to follow the natural flow of steroids produced in your own body and therefore to minimise side-effects. The response is almost always dramatic, the patient feeling back to normal with 48 hours. The starting dose is usually 20 mgm to 25 mgm daily; I preferred the 25 mgm as a sure-fire relief of symptoms is dramatic and appreciated (and the patient has often suffered enough), but that is balanced by assiduous tailored reduction to the smallest dose which maintains the “cure”. Usually the reduction in dose is by 2.5 mgm (there is a 2.5 mgm tablet as well as a 5 mgm and a 1mgm) every 2 or 3 weeks until reaching 10 mgm. Then the reduction is slower – by 1mgm per month or so – to maintain the cure. You will usually be completely off steroids by12 -18 months, though sometimes it takes longer.
Are there any problems or dangers with prolonged steroid treatment?
Most patients on long terms steroids for PMR, who keep their regular appointments, have no problems whatsoever, but some problems may rarely occur with prolonged high doseage:
Weight gain, especially around the abdomen; occasionally patients develop a puffy face (‘moon face’).
Easy bruising of the skin, sometimes with little or no trauma, such as on the back of the hands.
Some patients lose a little hair. Cataract development may be hastened.
Older patients, or those with a diagnosis of diabetes may experience rises in their blood sugar and the doctor will need to check the blood sugar more frequently.
There may be a slight rise in blood pressure and those with a known diagnosis of hypertension will need to have it checked (ideally check it yourself!) more often.
Bones can also become thinner and more brittle (osteoporosis) but this can be countered by preventative treatment with calcium, vitamin D and other drugs called drugs called bisphosphonates, tailored to the patient’s particular needs.
NB: Patients on corticosteroids should not stop their medication suddenly as this can lead to harm. Our bodies produce steroids naturally and increase production in times of crisis – injury, infection etc. Just as the supply of mains water to your home, would lead to neglect of the well, your own supply line of steroids are likely to be lessened when you are receiving them from outside. Any attending doctor should be informed that you are taking steroids.
NB and my own opinion: though this list sounds awful, patients with PMR usually have no problems whatsoever! And this is offset by the increase in mobility and quality of life. Untreated PMR is very, very bad for your health, Quality of Life and sanity!
Anything else I should know about it?
There is a related condition called “Temporal arteritis” of “Giant Cell arteritis”. In this condition, the arteries in the scalp become acutely painful, the patient feels very, very unwell and the blood markers for inflammation are raised to extremely high levels. Although less than one patient in eight with PMR has this condition, the symptoms of a tender scalp, pains in the scalp when eating or acute visual disturbance should prompt an urgent consultation, as there is a real risk of loss of sight!
Overall, however, the outlook is very bright; you should respond to treatment very promptly, and in working closely with your doctor and nurse, problems should be minimal.
Please feel free to contact me if there are any unexplained areas or indeed if you can improve on this handout! Above all Good Luck.
Bernard Shevlin (b.shevlin02@gmail.com)