You’re the resident doctor working in primary care; a patient comes in with symptoms such as neck ache and fatigue – what are the differentials you are going to consider?
It is common to experience tiredness and muscle pains with the wear and tear of daily life, or alongside common viral illnesses. Although these are reasonable considerations, it is important not to neglect other pathological causes of vague presentations.
What is PMR?
‘Polymyalgia rheumatica (PMR) is a chronic, systemic, rheumatic inflammatory disease’
It is characterised by pain and stiffness, particularly in the neck, shoulders and pelvic girdle.
PMR can present with very non-specific symptoms resulting in a lot of cases taking a while to diagnose. It is your job as a primary care clinician to keep a broad and open mind when patients present with such symptoms and ensure to keep rheumatological presentations in your medical sieve.
A cohort study found that 81.9% of cases referred to a rheumatologist with an ‘unknown diagnosis’ had PMR undetected by the GP.
Who does it affect?
PMR typically affects patients over 50 years of age, though the rates are significantly higher in those over 65.
The rates are much higher in women than in men and is most common in individuals of Northern European ancestry.
Typical symptoms of PMR
- Pain and stiffness in the shoulders, neck and hips
- Difficulty getting up from a chair
- Difficulty raising arms
- Weight loss
- Fatigue
- Low-grade fever
- Loss of appetite
- General malaise
In a similar fashion to Rheumatoid Arthritis, the stiffness is often worse in the morning and gradually improves as you become more active.
Management
Steroids, steroids, steroids!
Prednisolone is then gradually reduced over time dependent on the patient’s symptoms. Patients become particularly well versed with their steroid regime and adjust their doses based on the impact of their symptoms.
Beyond pharmacological management, it is important to provide patients with a steroid card and ensure that patients are well informed about the complications of steroids. Pointing patients in the direction of informative support groups, such as PMRGCA UK, can give patients a sense of community and provide a safe platform for questions and management advice.
Currently the only biological licenced for steroid resistant PMR is the IL-6 blocker Sarilumab (Kevzara). This is typically used to treat rheumatoid arthritis.
The future of management of PMR is unclear. Most patients have significant benefits from steroids, but it is important to remember the plethora of side effects / complications that can arise due to long term steroid use.
Common misconceptions
The main myth is that PMR only requires treatment for one to two years, and that patients will make a swift and total recovery. The lived experiences of patients do not mirror the statements commonly taught in medical schools.
Below is a link to the charity organisation ‘PMR GCA UK’ showing the true experiences and impact of PMR on the lives of many across the UK including a range of patient videos!
Another key consideration is Giant Cell Arteritis, for which our ophthalmology team have created a useful article
https://mindthebleep.com/giant-cell-arteritis/
Dr Olivia Beazer (FY2)
Reviewed by Dr Sarah Mackie, Consultant Rheumatologist
References
https://cks.nice.org.uk/topics/polymyalgia-rheumatica/background-information/prevalence
