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| {{Infobox_Disease |
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| Name = Polymyalgia rheumatica |
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| Image = |
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| Caption = |
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| DiseasesDB = |
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| ICD10 = {{ICD10|M|35|3|m|30}} |
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| ICD9 = {{ICD9|725}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000415 |
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| MeshID = |
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| }}
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| {{SI}}
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| {{EH}}
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| __NOTOC__ | | __NOTOC__ |
| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
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| '''For patient information click [[Polymyalgia rheumatica (patient information)|here]]''' | | '''For patient information click [[Polymyalgia rheumatica (patient information)|here]]''' |
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| ==Overview==
| | {{Polymyalgia rheumatica}} |
| [[Image:Bodydone.GIF|thumb|200px|In polmyalgia rheumatica (PMR), pain is usually located in the [[shoulders]] and [[hips]].]]
| | {{CMG}}; {{AE}} {{CZ}}, Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org], {{Rim}}, {{AEL}} |
| '''Polymyalgia rheumatica''' (PMR) - (in Greek meaning “pain in many muscles”) is an inflammatory condition of the [[muscles]], which causes pain or stiffness, usually in the [[neck]], shoulders, and hips. The pain can be very sudden, or can occur gradually over a period of time.
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| Most PMR sufferers wake up in the morning with pain in their [[muscles]]; however, there have been cases in which the patient has developed the pain during the evenings.<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref> Along with this disorder, there have been reports that patients who have polymyalgia rheumatica also have [[temporal arteritis]], which causes inflammation that damages large and medium size [[arteries]]. PMR usually goes away within a year or two after treatment.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| ==Causes==
| | {{SK}} Anarthritic Syndrome, Arthritic Rheumatoid Disease, Polymyalgia, PMR |
| The cause of this disorder is unknown; however, studies have shown that during this disorder, the [[white blood cells]] in the body attack the lining of muscle joints, causing inflammation.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref> Recent studies have found that inherited factors also play a role in the probability that an individual will become sick with polymyalgia rheumatica. Several theories have included viral stimulation of the [[immune system]] in genetically susceptible individuals.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/article.htm Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref>
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| Manifestation of [[gaintcell arteritis]] as polymyalgia rheumatica is associated with the increased frequency of [[HLA DR4]].<ref name="pmid3259885">{{cite journal |author=Cid MC, Ercilla G, Vilaseca J, ''et al.'' |title=Polymyalgia rheumatica: a syndrome associated with HLA-DR4 antigen |journal=Arthritis Rheum. |volume=31 |issue=5 |pages=678–82 |year=1988 |month=May |pmid=3259885 |doi= |url=}}</ref>.[[PMR]] and [[GCA]] also share the associated sequence polymorphism encoded by the second hypervariable region(HVR) of the [[HLA DRB1 gene]] unlike [[rheumatoid arthritis]] in which the sequence is encoded by third HVR.<ref name="pmid8147928">{{cite journal |author=Weyand CM, Hunder NN, Hicok KC, Hunder GG, Goronzy JJ |title=HLA-DRB1 alleles in polymyalgia rheumatica, giant cell arteritis, and rheumatoid arthritis |journal=Arthritis Rheum. |volume=37 |issue=4 |pages=514–20 |year=1994 |month=April |pmid=8147928 |doi= |url=}}</ref>. Isolated PMR has positive association with TNFb3, independent of HLA DRB1 association.<ref name="pmid10943865">{{cite journal |author=Mattey DL, Hajeer AH, Dababneh A, ''et al.'' |title=Association of giant cell arteritis and polymyalgia rheumatica with different tumor necrosis factor microsatellite polymorphisms |journal=Arthritis Rheum. |volume=43 |issue=8 |pages=1749–55 |year=2000 |month=August |pmid=10943865 |doi=10.1002/1529-0131(200008)43:8<1749::AID-ANR11>3.0.CO;2-K |url=}}</ref>
| | ==[[Polymyalgia rheumatica overview|Overview]]== |
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| Several [[viruses]] are thought to be linked to polymyalgia rheumatica,including the [[adenovirus]], which causes respiratory infections; the human parvovirus B19, an infection that affects children; and the human parainfluenza virus..<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
| | ==[[Polymyalgia rheumatica historical perspective|Historical Perspective]]== |
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| == Differential Diagnosis == | | ==[[Polymyalgia rheumatica classification|Classification]]== |
| * [[Rheumatoid arthritis]] - Polymyalgia rheumatica and late onset rheumatoid arthritis can initially present with similar clincal features like synovitis. These patients are treated initially as PMR with gluococorticoids. RA treatment is started when there is no improvement or when it evolves into charecteristic RA or when there is a persistently raised plasma viscosity.<ref name="pmid18980958">{{cite journal |author=Pease CT, Haugeberg G, Montague B, ''et al.'' |title=Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study |journal=Rheumatology (Oxford) |volume=48 |issue=2 |pages=123–7 |year=2009 |month=February |pmid=18980958 |doi=10.1093/rheumatology/ken343 |url=}}</ref> <ref name="pmid15940765">{{cite journal |author=Pease CT, Haugeberg G, Morgan AW, Montague B, Hensor EM, Bhakta BB |title=Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation |journal=J. Rheumatol. |volume=32 |issue=6 |pages=1043–6 |year=2005 |month=June |pmid=15940765 |doi= |url=}}</ref>
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| * [[Polymyositis]] and Dermatomyositis - Patients with dermatomyositis or polymyositis present with tenderness and weakness of proximal muscles, while PMR patients present with pain and stiffness prominently. This differentiation may be difficult in elderly patients. Proper history,complete physical examination, ESR,creatine kinase levels and muscle biopsy help in establishing proper diagnosis.<ref name="pmid21040663">{{cite journal |author=Sørensen CD, Hansen LH, Hørslev-Petersen K |title=[Myositis as differential diagnosis in polymyalgia rheumatica] |language=Danish |journal=Ugeskr. Laeg. |volume=172 |issue=42 |pages=2899–900 |year=2010 |month=October |pmid=21040663 |doi= |url=}}</ref> <ref name="pmid2042988">{{cite journal |author=Hopkinson ND, Shawe DJ, Gumpel JM |title=Polymyositis, not polymyalgia rheumatica |journal=Ann. Rheum. Dis. |volume=50 |issue=5 |pages=321–2 |year=1991 |month=May |pmid=2042988 |pmc=1004419 |doi= |url=}}</ref>
| | ==[[Polymyalgia rheumatica pathophysiology|Pathophysiology]]== |
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| * Malignancy ([[myeloma]], others) - Patients with malignancy sometimes present with PMR like symptoms and have poor response to steroid therapy<ref name="pmid3774196">{{cite journal |author=Manganelli P, Borghi L, Coruzzi P, Novarini A, Ambanelli U |title=[Paraneoplastic polymyalgia rheumatica. Case contribution] |language=Italian |journal=Minerva Med. |volume=77 |issue=38 |pages=1739–41 |year=1986 |month=October |pmid=3774196 |doi= |url=}}</ref>. This is in fact paraneoplastic syndrome presenting as PMR.<ref name="pmid19562970">{{cite journal |author=Kwiatkowska B, Filipowicz-Sosnowska A |title=[Polymyalgia rheumatica mimicking neoplastic disease--significant problem in elderly patients] |language=Polish |journal=Pol. Arch. Med. Wewn. |volume=118 Suppl |issue= |pages=47–9 |year=2008 |pmid=19562970 |doi= |url=}}</ref>
| | ==[[Polymyalgia rheumatica causes|Causes]]== |
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| *[[Fibromyalgia]] - [[Fibromyalgia]] is commonly presented in age groups 20-50 years and patients have characteristic tender points. The active phase protiens and [[ESR]] are normal unlike [[PMR]].
| | ==[[Differentiating Polymyalgia rheumatica from other diseases|Differentiating Polymyalgia Rheumatica from other Diseases]]== |
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| *[[Hyperparathyroidism]] - [[Hyperparathyroidism]] presents with proximal stiffness and bone pain with elevated [[parathyroid hormone]] levels and often [[calcium]] levels without elevation of [[ESR]] levels.
| | ==[[Polymyalgia rheumatica epidemiology and demographics|Epidemiology and Demographics]]== |
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| * Chronic infection ([[subacute bacterial endocarditis]] ([[SBE]])) - Rheumatologic symptoms seen in [[infective endocarditis]] can present a clinical picture suggesting [[polymyalgia rheumatica]] hindering the correct diagnosis.<ref name="pmid16859595">{{cite journal |author=Auzary C, Le Thi Huong D, Delarbre X, ''et al.'' |title=Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis |journal=Clin. Exp. Rheumatol. |volume=24 |issue=2 Suppl 41 |pages=S38–40 |year=2006 |pmid=16859595 |doi= |url=}}</ref>
| | ==[[Polymyalgia rheumatica risk factors|Risk factors]]== |
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| * [[Hypothyroidism]] - These patients have signs like muscle and joint pain and weakness similar to [[PMR]]. Delayed relaxation of deep tendon reflexes is seen in [[hypothyroidism]] with elevated [[TSH]] levels and low [[T4]] levels.
| | ==[[Polymyalgia rheumatica screening|Screening]]== |
| *[[Remitting seronegative symmetrical synovitis with pitting edema]] - [[RS3PE]] presents with symmetrical [[synovitis]] and [[pitting edema]],usually in patients over 50 years of age and lack [[rheumatoid factor]]. The symptoms are commonly manifested distally unlike [[PMR]].
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| == Epidemiology and Demographics == | | ==[[Polymyalgia rheumatica natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * Mean age at onset ~ 70 (range 50-90)
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| * F:M ratio = 2:1
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| ==Risk Factors==
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| There are no certain circumstances for which an individual will get polymyalgia rheumatica, but there are a few factors that show a relationship with the disorder.
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| *Usually affects adults over the age of 50<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *The average age of a person who has PMR is about 70 years old<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *Women are twice as likely to get PMR as men<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *The vast majority of people affected are white<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *50% of people with [[temporal arteritis]] also have polymyalgia rheumatica<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *Smoking, sun exposure, infections, nulliparity are also considered risk factors.<ref name="pmid10948749">{{cite journal |author=Cimmino MA, Zaccaria A |title=Epidemiology of polymyalgia rheumatica |journal=Clin. Exp. Rheumatol. |volume=18 |issue=4 Suppl 20 |pages=S9–11 |year=2000 |pmid=10948749 |doi= |url=}}</ref>
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| == History and Symptoms ==
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| There are a wide range of symptoms that indicate if a person has polymyalgia rheumatica. The symptoms include pain and stiffness in the [[muscles]], usually in the [[neck]], [[shoulders]], and [[hips]]. The pain is moderate to severe, and may inhibit the activity of the person. These symptoms usually occur in the morning, or after sleeping. [[Fatigue]] and [[lack of appetite]] are also signs of polymyalgia rheumatica. [[Lack of appetite]] could lead to unintentional [[weight loss]]. [[Anemia]] is another sign of polymyalgia rheumatica. An overall [[feeling of illness]] and a slight [[fever]] are also signs of this disorder.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Studies have shown that about 15% of people who are diagnosed with polymyalgia rheumatica also have [[temporal arteritis]], and about 50% of people with [[temporal arteritis]] have polymyalgia rheumatica. Some symptoms of [[temporal arteritis]] include severe[[headaches]], scalp tenderness, [[jaw]] or facial soreness, distorted vision or aching in the limbs caused by decreased blood flow, and [[fatigue]].<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| * Symmetric aching/stiffness of axial & proximal limb musculature
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| *:* Shoulder girdle, neck, hip girdle
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| *:* Morning stiffness, gelling
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| * Muscle strength intact, though may be limited by pain
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| * [[Synovitis]] in knees, wrists, sterno-clavicular (SC) joints, hips/shoulders
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| * Distal extremity swelling ([[tenosynovitis]])
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| * [[Malaise]], [[fatigue]], [[weight loss]] in > 50%
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| ==== Relation to Giant Cell Arteritis (GCA) ==== | |
| * 25% of patients with GCA have PMR as presenting symptom
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| * 40-60% of patients with GCA have PMR during disease course
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| * 10-15% of patients with PMR have GCA by temporal artery (TA) biopsy
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| <br>
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| {|
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| |-style="background:silver; color:black"
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| | '''''Symptoms GCA''''' || || '''''Signs GCA''''' ||
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| |-style="background:silver; color:black"
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| | '''Headache''' || '''68%''' || '''Decreased TA pulsations''' || '''46%'''
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| |- style="background:silver; color:black"
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| | '''Jaw claudication''' || '''45%''' || '''Fever''' || '''42%'''
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| |-style="background:silver; color:black"
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| | '''Transient visual symptoms''' || '''16%''' || '''Tenderness over temporal artery''' || '''27%'''
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| |-style="background:silver; color:black"
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| | '''Fixed visual loss''' || '''14%''' || '''Nodular or swollen scalp arteries''' || '''23%'''
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| |-style="background:silver; color:black"
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| | '''Dysphagia ''' || '''8%''' || '''Large artery bruits ''' || '''21%'''
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| |-style="background:silver; color:black"
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| | '''Tongue claudication''' || '''6%''' || '''Ophthalmoscopic abnormalities''' || '''18%'''
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| |-style="background:silver; color:black"
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| | || || '''Visual loss''' || '''14%'''
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| |}
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| ==Diagnosis== | | ==Diagnosis== |
| There is no specific test to diagnose polymyalgia rheumatica. There are many other diseases which cause inflammation and pain in [[muscles]], but there are a few tests that can help narrow down the cause of the pain. Limitation in shoulder motion, or swelling of the joints in the wrists or hands are noted by the doctor.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/article.htm Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref> The doctor will assess the patient’s pain, and may perform one of the following tests to determine if polymyalgia rheumatica is indeed the cause of the pain.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| One test that is usually performed is the [[erythrocyte sedimentation rate]] test (also known as the [[ESR]] or [[SED rate]]), which is a [[blood test]] that checks the [[erythrocyte sedimentation rate]]. This test measures how fast the patient’s red blood cells settle in a test tube. The faster the blood cells settle, the higher the SED rate, which means that there is inflammation. Because many conditions can cause an elevated SED rate, this test alone is not a good determinant if a person has with polymyalgia rheumatica.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Another test that checks the level of [[C-reactive protein]] in the blood may also be conducted. [[C-reactive protein]] is produced by the liver in response to an injury or infection. People with polymyalgia rheumatica usually have high levels of [[C-reactive protein]], which is a response due to inflammation.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Because people with polymyalgia rheumatica are sometimes associated with [[temporal arteritis]], doctors may perform a test to determine if a person has [[temporal arteritis]]. A sample from the scalp artery in the temple is taken and examined under a microscope. If a person is positive for [[temporal arteritis]], the doctor may prescribe a medicine that treats both polymyalgia rheumatica and [[temporal arteritis]].<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| As a summary;
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| * Age ≥ 50 at onset
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| * Symtoms in ≥ 2/3 areas (shoulder girdle, hip girdle, neck) x ≥ 1 month
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| * Erythrocyte sedimentation rate (ESR) ≥ 40 mm/hr
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| * Exclusion of alternative diagnosis
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| 2012 provisional criteria for Polymyalgia rheumatica by EULAR/ACR : patient ><u></u>50 years old presenting with bilateral shoulder pain, not explained by an alternative pathology can be classified as PMR in the presence of morning stiffness >45 minutes, elevated CRP and/or ESR and new hip pain.<ref name="pmid22388996">{{cite journal |author=Dasgupta B, Cimmino MA, Maradit-Kremers H, ''et al.'' |title=2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative |journal=Ann. Rheum. Dis. |volume=71 |issue=4 |pages=484–92 |year=2012 |month=April |pmid=22388996 |pmc=3298664 |doi=10.1136/annrheumdis-2011-200329 |url=}}</ref>
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| == Laboratory Findings ==
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| * Mild normochromic, normocytic anemia (during active phase)
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| * [[White blood cell]] ([[WBC]]) normal, [[platelets]] often increased
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| * Markedly elevated [[ESR]]
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| * [[Antinuclear antibody]] (ANA), [[rheumatoid factor]] (RF) usually negative
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| *Elevation of [[alkaline phosphatase]] of [[liver]] origin is seen in one third to half of patients with [[PMR]] associated with [[GCA]].<ref name="pmid1807822">{{cite journal |author=Kyle V |title=Laboratory investigations including liver in polymyalgia rheumatica/giant cell arteritis |journal=Baillieres Clin Rheumatol |volume=5 |issue=3 |pages=475–84 |year=1991 |month=December |pmid=1807822 |doi= |url=}}</ref>
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| * [[Creatine kinase]] (CK), aldolase, [[electromyogram]] (EMG), [[muscle biopsy]] all normal
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| === Other Diagnostic Studies ===
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| ==== Temporal Artery Biopsy ====
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| * Not indicated if no symptoms suggestive of GCA
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| * Negative predictors of GCA
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| *:* Age < 70
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| *:* Absence of headache or jaw claudication
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| *:* Clinically normal temporal arteries
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| *:* 3 negative predictors--1.7% risk GCA
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| *:* If ≤ 2 negative predictors--55% risk GCA
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| * Can still demonstrates arteritis after 2-4 weeks of steroid treatment
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| ==== Ultrasound and MRI ====
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| *[[Ultrasonography]] is effective in confirming bilateral [[subacromial]] and [[subdeltoid bursitis]] in [[PMR]] patients.<ref name="pmid11361188">{{cite journal |author=Cantini F, Salvarani C, Olivieri I, ''et al.'' |title=Shoulder ultrasonography in the diagnosis of polymyalgia rheumatica: a case-control study |journal=J. Rheumatol. |volume=28 |issue=5 |pages=1049–55 |year=2001 |month=May |pmid=11361188 |doi= |url=}}</ref>
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| *[[MRI]] is used in the assessment of [[hip synovitis]] and [[iliopsoas bursitis]]. It is sensitive than [[ultrasonography].<ref name="pmid16095113">{{cite journal |author=Cantini F, Niccoli L, Nannini C, ''et al.'' |title=Inflammatory changes of hip synovial structures in polymyalgia rheumatica |journal=Clin. Exp. Rheumatol. |volume=23 |issue=4 |pages=462–8 |year=2005 |pmid=16095113 |doi= |url=}}</ref>
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| *[[MRI]] and [[Ultrasound]] of the shoulder facilitate the proper diagnosis in patients with the typical proximal symptoms of [[PMR]] with normal [[ESR]] values.<ref name="pmid11352249">{{cite journal |author=Cantini F, Salvarani C, Olivieri I, ''et al.'' |title=Inflamed shoulder structures in polymyalgia rheumatica with normal erythrocyte sedimentation rate |journal=Arthritis Rheum. |volume=44 |issue=5 |pages=1155–9 |year=2001 |month=May |pmid=11352249 |doi=10.1002/1529-0131(200105)44:5<1155::AID-ANR198>3.0.CO;2-N |url=}}</ref>
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| *[[Ultrasound]] is useful in monitoring the patients' response to the [[corticosteroid]] treatment and detects any subclinical [[inflammation]].<ref name="pmid19773289">{{cite journal |author=Jiménez-Palop M, Naredo E, Humbrado L, ''et al.'' |title=Ultrasonographic monitoring of response to therapy in polymyalgia rheumatica |journal=Ann. Rheum. Dis. |volume=69 |issue=5 |pages=879–82 |year=2010 |month=May |pmid=19773289 |doi=10.1136/ard.2009.113555 |url=}}</ref>.[[Power Doppler ultrasound]] is useful in detecting patients with high [[inflammation]] who have a high risk of relapses or recurrences.<ref name="pmid19808693">{{cite journal |author=Macchioni P, Catanoso MG, Pipitone N, Boiardi L, Salvarani C |title=Longitudinal examination with shoulder ultrasound of patients with polymyalgia rheumatica |journal=Rheumatology (Oxford) |volume=48 |issue=12 |pages=1566–9 |year=2009 |month=December |pmid=19808693 |doi=10.1093/rheumatology/kep286 |url=}}</ref>
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| ==== PET Scan ====
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| [[PET scan]] has no proven clinical value in patient care. [[18-fluorodeoxyglucose]] accumulation in the [[blood vessels]] suggests [[arteritis]],mostly in the large vessels. [[Region of index]] analysis is sensitive tool in detecting such [[inflammation]].<ref name="pmid15194587">{{cite journal |author=Moosig F, Czech N, Mehl C, ''et al.'' |title=Correlation between 18-fluorodeoxyglucose accumulation in large vessels and serological markers of inflammation in polymyalgia rheumatica: a quantitative PET study |journal=Ann. Rheum. Dis. |volume=63 |issue=7 |pages=870–3 |year=2004 |month=July |pmid=15194587 |pmc=1755055 |doi=10.1136/ard.2003.011692 |url=}}</ref>[[FDG]] focal uptake is seen in [[ligament]] [[inflammation]].<ref name="pmid22475905">{{cite journal |author=Adams H, Raijmakers P, Smulders Y |title=Polymyalgia rheumatica and interspinous FDG uptake on PET/CT |journal=Clin Nucl Med |volume=37 |issue=5 |pages=502–5 |year=2012 |month=May |pmid=22475905 |doi=10.1097/RLU.0b013e3182485098 |url=}}</ref>
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| ==Treatment and Medication==
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| Anti-inflammatory medicine such as [[aspirin]] or [[ibuprofen]] is typically prescribed to treat mild cases of polymyalgia rheumatica. For more serious cases, with extreme pain and discomfort, [[steroids]] are prescribed to patients. [[Prednisone]] is the typical [[steroid]] used to treat polymyalgia rheumatica. The [[steroids]] are normally distributed in low doses (10-15 mg per day), and results are usually seen within the first few days of taking the medication.<ref name="citation4">http://www.rheumatology.org/public/factsheets/pmr_new2.asp "POLYMYALGIA RHEUMATICA." American College of Rheumatology. June 2006. American College of Rheumatology. 11 Mar. 2008 </ref> The patient's SED rate is monitored throughout the medication process, and other [[blood tests]] are conducted to make sure the patient does not experience any side effects from the treatment. Once the SED rate is back to normal, the patient will receive lower doses of the [[steroids]] in order to avoid any long term health effects from the [[steroids]].<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref> Intramuscular methylprednisolone(40-120 mg)has similar effects like oral corticosteroids and the cumulative steroid dose is also less.<ref name="pmid1768166">{{cite journal |author=Dasgupta B, Gray J, Fernandes L, Olliff C |title=Treatment of polymyalgia rheumatica with intramuscular injections of depot methylprednisolone |journal=Ann. Rheum. Dis. |volume=50 |issue=12 |pages=942–5 |year=1991 |month=December |pmid=1768166 |pmc=1004588 |doi= |url=}}</ref>
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| Some side effects from the [[steroids]] may occur. Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]]. The doctor should be notified of any signs of sickness.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref> Methylprednisolone has better side effect profile with respect to fracture rate and weight gain.<ref name="pmid10948765">{{cite journal |author=Li C, Dasgupta B |title=Corticosteroids in polymyalgia rheumatica--a review of different treatment schedules |journal=Clin. Exp. Rheumatol. |volume=18 |issue=4 Suppl 20 |pages=S56–7 |year=2000 |pmid=10948765 |doi= |url=}}</ref> Prophylaxis for osteoporosis with calcium and vitamin D should be started along with steroid therapy.
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| Along with medical treatment, patients can increase their chances of recovery by exercising and eating healthy foods. [[Exercise]] will help strengthen the weak [[muscles]], and help to prevent weight gain. A healthy diet will help to keep a strong [[immune system]], and also help build strong muscles and bones.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Treatment lasts as long as needed; however, it normally takes patients several years to get off of the steroids. The symptoms may come back when the dosage is lowered.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/page2.htm#6whatis Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref>
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| === Acute Pharmacotherapies ===
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| * [[NSAID]]s helpful in mild disease
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| * [[Glucocorticoids]] if no response to [[non-steriod anti inflammatory drug]]s ([[NSAID]]s)
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| *:* [[Prednisone]] 5-20 mg every day--rapid improvement in symptoms
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| *:* Start taper after symptoms remit and ESR returns to normal (2-4 weeks)
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| *:* Gradual dose reduction (eg, by 2.5 mg) q 1-4 weeks until dose = 5-10 mg every day
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| *:* Even ''slower'' taper once dose < 5-10 mg (reduce dose by 1 mg q month)
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| * Monitor for relapse--occurs in 25-50%, usually because taper too rapid
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| * Careful observation for signs of [[arteritis]]
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| === Other therapies ===
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| Glucocorticoids are considered the most effective medication for polymyalgia rheumatica. Other medications are considered in steroid resistant cases i.e no good response with 20mg/day prednisone, atypical cases and in patients at high risk for steroid related toxicity.
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| *Methotrexate is the commonly used steroid sparing agent.Prednisone plus methotrexate treatment is associated with shorter prednisone treatment.<ref name="pmid15466766">{{cite journal |author=Caporali R, Cimmino MA, Ferraccioli G, ''et al.'' |title=Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=7 |pages=493–500 |year=2004 |month=October |pmid=15466766 |doi= |url=}}</ref>
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| *Infliximab use in PMR has not been proved beneficial and it may be harmful.<ref name="pmid17470831">{{cite journal |author=Salvarani C, Macchioni P, Manzini C, ''et al.'' |title=Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=9 |pages=631–9 |year=2007 |month=May |pmid=17470831 |doi= |url=}}</ref>
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| *Etanercept may be safe and useful in relapsing PMR. It is modestly effective in PMR associated with giantcell arteritis than in isolated PMR
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| EULAR response criteria for PMR comprise a set of core markers for monitoring therapeutic response which include :
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| *[[ESR]]
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| *[[CRP]]
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| *Visual analogue scale of patient's pain
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| *[[Physician's global assessment]]
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| *[[Morning stiffness]]
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| *Ability to elevate the [[upper limbs]].
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| A disease activity score <7 indicates low activity, 7-17 suggest medium disease activity, >17 indicates high disease activity.<ref name="pmid16823992">{{cite journal |author=Nothnagl T, Leeb BF |title=Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica |journal=Drugs Aging |volume=23 |issue=5 |pages=391–402 |year=2006 |pmid=16823992 |doi= |url=}}</ref>
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| ==References==
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| <references />
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| ==External links==
| | [[Polymyalgia rheumatica diagnostic study of choice|Diagnostic Study of Choice]] | [[Polymyalgia rheumatica history and symptoms|History and Symptoms]] | [[Polymyalgia rheumatica physical examination|Physical Examination]] | [[Polymyalgia rheumatica laboratory findings|Laboratory Findings]] | [[Polymyalgia rheumatica electrocardiogram|Electrocardiogram]] | [[Polymyalgia rheumatica x ray|X-ray]] | [[Polymyalgia rheumatica echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Polymyalgia rheumatica CT scan|CT scan]] | [[Polymyalgia rheumatica MRI|MRI]] | [[Polymyalgia rheumatica other imaging findings|Other Imaging Findings]] | [[Polymyalgia rheumatica other diagnostic studies|Other Diagnostic Studies]] |
| * [http://www.webmd.com/content/article/78/95605.htm?z=2953_00483_6501_00_29 Polymyalgia Rheumatica] - WebMD.com
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| * [http://www.arthritis.ca/types%20of%20arthritis/polymyalgia%20rheumatica/default.asp?s=1 Polymyalgia Rheumatica] - The Arthritis Society
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| * [http://www.rheumatology.org/public/factsheets/pmr_new2.asp Patient Education - Polymyalgia Rheumatica] - American College of Rheumatology
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| * [http://nmrfoundation.blogspot.com/ National Medical Research Foundation] Support groups for people with polymyalgia rheumatica
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| | ==Treatment== |
| | [[Polymyalgia rheumatica medical therapy|Medical Therapy]] | [[Polymyalgia rheumatica surgery|Surgery]] | [[Polymyalgia rheumatica primary prevention|Primary Prevention]] | [[Polymyalgia rheumatica secondary prevention|Secondary Prevention]] | [[Polymyalgia rheumatica cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Polymyalgia rheumatica future or investigational therapies|Future or Investigational Therapies]] |
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| {{Diseases of the musculoskeletal system and connective tissue}}
| | ==Case Studies== |
| {{SIB}}
| | [[Polymyalgia rheumatica case study #1|Case Study #1]] |
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