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, MB, ChB, FRCP(Glas), DA
General Practitioner, Glasgow
Past President of the Primary Care Rheumatology Society
The presence of any 3 of these criteria gives a sensitivity of 92% and a specificity of 80% for the diagnosis of PMR.2 If
The diagnosis of polymyalgia rheumatica (PMR) can present
an additional criterion of a rapid response to oral steroid
a difficult challenge in primary care as there are no specific
therapy is added, this increases the sensitivity to 99%.2
diagnostic tests and diagnosis depends on having a high index of suspicion supported by history, examination and
The Bird criteria are very useful and easy to apply in primary
raised inflammatory markers. On the other hand, PMR
care, although it should be noted that they do not yet have
can be a very satisfying condition to treat in primary care
universal acceptance in the rheumatological community as
as patients often have a very dramatic response to steroid
therapy and are very grateful for the prompt relief of their symptoms.
Clinical features of PMR
Epidemiology of PMR
Clinical features include:• stiffness and pain in shoulder and pelvic girdles
The epidemiology of PMR varies according to different stud-
ies with the incidence per 100,000 of the population aged
• often systemic features of debility, weight loss, tiredness
over 50 reported between 13 and 68. The incidence incr-
eases with increasing age and there is an M:F ratio of 1:2.
dramatic onset of pain and stiffness or:
insidious onset with less stiffness and pain and
Diagnostic criteria for PMR
more systemic features.
Stiffness is usually the main feature. Affected muscles
Various authors have tried to set out diagnostic criteria for
may be tender but the joints themselves are not usually
PMR, all of which include a combination of age, clinical
features and a raised erythrocyte sedimentation rate (ESR). Bird et al1 list six criteria:
The diagnosis can be straightforward in patients who pres-ent with a sudden onset of symptoms associated with a
TABLE 1. Criteria for diagnosis of polymyalgia
raised ESR. Some patients, however, present with a more
insidious onset. In these patients systemic features may be more prominent, making the diagnosis much more
difficult, and in these cases a wide range of differential
diagnoses may need to be considered. These include:
The presence of 3 or more of the above 6 criteria is
ESR erythrocyte sedimentation rate; PMR polymyalgia rheumatica
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• fibromyalgia• shoulder problems (e.g. capsulitis or tears of the
Straightforward cases of PMR can be managed successfully
within primary care. Unless there are any contraindications patients should be started on 15 mg prednisolone per day, which should bring rapid relief of symptoms within a few
Investigations for suspected PMR
There is no specific test for PMR, although most patients
If this does not happen, reconsider your diagnosis.
will have a significantly raised ESR. If you suspect PMR it is worthwhile doing the following investigations:
The dose of prednisolone should then be titrated down slowly according to symptoms rather than ESR. The dose
TABLE 2. Investigations for suspected PMR.
can often be reduced fairly rapidly down to 10 mg per day and then reduced by 1 mg daily per 4–6 weeks over
6–12 months down to 5 mg daily. Then the dose should be
reduced more slowly, aiming to have the patient off steroid
therapy by around 2 years, although some patients may
require a small dose of steroids for 3–4 years.
As they are weaned off corticosteroid therapy some patients may require a small dose of NSAIDs at this stage to reduce
ESR erythrocyte sedimentation rate; FBC full blood count; LFT liver
the muscle pain that sometimes occurs.
function tests; PMR polymyalgia rheumatica
Remember that steroid therapy has risks and side-effects
Although the ESR is usually significantly raised in PMR there
are some patients in whom the ESR is normal or only a little
• risk of osteoporosis
– bone protection therapy should be
raised. In these patients and in those presenting with sys-
initiated at the time of starting steroid therapy. Bone is
temic features other causes of illness should be excluded.
lost rapidly in the early stages of steroid therapy so treatment should not be delayed while awaiting a
Rheumatoid arthritis in an older patient may present with
dual-energy x-ray absorptiometry (DEXA) scan. In those
symptoms of PMR with shoulder girdle pain and stiffness.
patients aged over 65 and in those with a previous frac-
Be aware of the possibility of a polymyalgic presentation of
ture a DEXA scan is not necessary as these patients are at
considerable increased risk of osteoporosis and sub-
• there are peripheral joint signs such as synovitis
sequent fracture and require continued bone protection
• there is a failure to respond to an adequate dose of
• gastric irritation
– gastro-protection may be required.
• the initial dose of steroid cannot be reduced without exacerbating the symptoms.
If the diagnosis remains unclear, re-examine the patient
Relapses are common in PMR and should be diagnosed on
thoroughly with other diagnoses in mind. At this stage other
clinical grounds rather than relying on ESR. They are usually
investigations may be useful. Consider the following :
caused by an overly rapid decrease in the dose of cortico-steroid and should be treated by increasing the dose again and then titrating down more slowly. If the steroid dose
TABLE 3. Useful investigations to aid differential
cannot be reduced without exacerbating the symptoms
in PMR, or if the patient suffers several relapses, consider
another diagnosis – especially rheumatoid arthritis.
Relapses are commoner in the first 6–12 months of treat-
ment and relapse rates are between 30 and 60%.
The long-term prognosis of PMR is good. Many patients can
stop their steroid treatment at around 2 years, although
some patients may require a small dose of steroids over
several years. This is more likely to occur in females, and in
ANA antinuclear antibodies; CPK creatine phosphokinase
those who were older and with a higher ESR at diagnosis.
Referral to secondary care
• in whom the diagnosis is unclear• who have repeated relapses.
Most straightforward cases of PMR can be managed within
primary care. In others however diagnosis and manage-
1. Bird HA, Esselinckx W, Dixon AS, Mowat AG, Wood PHN. An eval-
ment may be difficult and these cases should be referred to
uation of criteria for polymyalgia rheumatica. Ann Rheum Dis
a rheumatologist. Such patients may include those:
• who have an inadequate response to steroids
2. Bird H. European diagnostic criteria for polymyalgia rheumatica.
• in whom it is difficult to reduce the steroid dose with-
3. Samanta A, Kendall J. A fresh look at polymyalgia rheumatica.
Rheumatology (Oxford) 2002;41:1455-6.
Rheumatology Research Unit, Addenbrooke’s Hospital, Cambridge
Past President of the British Society for Rheumatology
The cardinal symptoms of PMR – prolonged morning stiffness
jaw claudication, as the catastrophic sequela of untreated
in the shoulder and pelvic girdles with an elevated ESR – are
GCA is irreversible blindness. In such cases higher doses of
generally straightforward. However PMR is essentially a diag-
prednisolone are required with possible referral for temporal
nosis of exclusion. As the differential diagnosis is extensive it
is important to exclude more sinister conditions at the outset with screening blood investigations. PMR is exceedingly rare
Education is paramount in PMR and patients should be
below the age of 50 and occasionally the ESR is misleading,
warned that treatment is usually necessary for at least 2
being normal or only slightly raised.
years, with some requiring long-term maintenance therapy. In prednisolone-resistant cases response to steroid-sparing
Of particular importance is the link between PMR and giant
cell arteritis (also known as temporal arteritis). Many authori-ties believe the two represent opposite ends of the spectrum
If diagnosis is proving difficult referral to a rheumatologist is
of the same disease. In any patient who presents with PMR it
prudent. However the treatment of a classic case of PMR is
is mandatory to ask about headache, scalp tenderness and
highly effective and one of the most satisfying in medicine.
PMR case study
• Mrs X, aged 88, presented with a 2-week history of pain
perhaps starting at a dose of 15 mg daily on the presump-
and stiffness in her neck and shoulders and to a lesser
tive diagnosis of PMR? On the other hand if the diagnosis
extent around her hips. On examination she had a reason-
turned out to be RA perhaps oral steroids would not be the
able range of movement of her neck but some difficulty in
raising her arms above her head. Past history included
• Following discussion with a consultant rheumatologist col-
osteoarthritis of the spine and hip with a hip replacement
league we decided that the best option was to give a dose
of intramuscular steroid and review at hospital out-
• At this stage it was thought that she probably had PMR and
investigations of ESR, CRP, FBC and rheumatoid factor were
• Because of her on-going symptoms we also added a COX-2
undertaken. While awaiting the ESR result she was treated
inhibitor and amitriptyline to her medication at this stage.
with analgesics rather than anti-inflammatory drugs
• She responded well to the steroid injection with resultant
because of a history of hiatus hernia and oesophageal
decrease in stiffness and pain allowing her to attend her
• Initial results showed a normal ESR of 5, raised CRP of 32
• Subsequent ESR was reported as 99 and to date the patient
with a normal FBC, with rheumatoid factor still awaited.
has not developed any signs of synovitis. She is still await-
• At this stage the patient’s stiffness and pain worsened to
the extent that she was unable to dress herself and spent her nights sitting in a chair as she felt unable to lie down in
This case study illustrates the difficulty we often have in
bed because of her symptoms. She complained of feeling
Primary Care in making a diagnosis between PMR and
generally unwell, with loss of appetite.
• The differential diagnosis remained between PMR and RA.
Signs and symptoms seemed more in favour of PMR but
Confounding factors in this instance were:
ESR was only 5. At this stage we received the rheumatoid
factor result which was 382 (normal 0–22). Although care-
• high level of rheumatoid factor
ful examination of the patient showed no evidence of
synovitis it was possible that this was a case of RA with a
Often the situation only clarifies as time goes on.
Perhaps this patient should have been treated with oral
• This patient was miserable and needed treatment to allevi-
ate her symptoms. Should we treat her with oral steroids,
Suggested PMR audit
It is a useful exercise to take a retrospective look at the care and clinical course of patients within your practice with a diagnosis of PMR. Useful data to collect includes:
• age at diagnosis• presenting symptoms and signs• initial ESR• starting dose of prednisolone• whether there was a dramatic response to treatment• whether patients received osteoporosis advice or treatment• number of relapses• total length of treatment with steroid therapy• referrals to secondary care• any laboratory tests such as thyroid function and rheumatoid factor.
An audit of PMR was undertaken in 1993 by GP members of the Primary Care Rheumatology Society. Data from 47 patients in primary care were analysed retrospectively. The M:F ratio was 17:30 and the mean age at diagnosis was 69.6 years.
• 18 (38%) suffered 2 or more (1 patient had 6)
Mean initial starting dose of prednisolone
Audits undertaken today should show a lower initial starting dose of prednisolone (around 15 mg) and a much higher percen-tage of patients counselled regarding, or treated for, osteoporosis. Only 38% of patients in the audit above were noted to have been given treatment or counselling about the risk of osteoporosis. The new Guidelines on corticosteroid induced osteoporosis1 advise starting bone protective therapy at the same time as starting steroid therapy in all patients aged over 65 or with ahistory of fragility fracture.
1. Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment. London: Royal College of Physicians of London; 2002.
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Biotechnol. Appl. Biochem. (2001) 33 , 85–89 (Printed in Great Britain) Erythrocyte-mediated delivery of dexamethasone in patients with chronic obstructive pulmonary disease Luigia Rossi*, Sonja Serafini*, Luigi Cenerini † , Francesco Picardi † , Leonardo Bigi ‡ , Ivo Panzani ‡ and Mauro Magnani*1 * Istituto di Chimica Biologica ‘ G . Fornaini ’, Universita Z d