Polymyalgia rheumatica: A closer look at causes, symptoms, and treatment

Polymyalgia rheumatica is a condition that can bring a profound sense of discomfort and a series of symptoms that can disrupt daily life. Characterised primarily by widespread stiffness, polymyalgia rheumatica typically affects people over the age of 50.

Here, Dr Ziad Farah, renowned consultant in rheumatology and general internal medicine, offers an expert insight into the causes, symptoms, and treatment of polymyalgia rheumatica.

What is polymyalgia rheumatica?

Polymyalgia rheumatica is an inflammatory autoimmune condition characterised by inflammation affecting the shoulders and the hips. It's mainly caused by inflammation of the bursa and the tendons. The bursa are little cushions that sit between our tendons. If the bursa get inflamed, then that can cause significant pain and stiffness, particularly around the shoulders and the thighs.

What are the signs and symptoms of polymyalgia rheumatica?

The main sign and symptom of polymyalgia rheumatica is stiffness. Stiffness is mostly in the morning and it can last for over 30 minutes, sometimes several hours. The stiffness can lead to restriction of movement where, for example, patients complain that they're unable to wash their hair or sit up from the chair because they're feeling significant stiffness. Pain is also a feature, although it's less common than stiffness itself.

As a result of these symptoms, patients can sometimes complain of feeling very tired, fatigued. Sometimes, patients have also lost a bit of weight in that time. Very rarely, this can cause some fevers and more constitutional symptoms like feeling a bit sweaty and generally unwell.

Can polymyalgia rheumatica cause complications if left untreated?

If polymyalgia rheumatica is left untreated, it can cause some complications. In general, the main complication is increasing stiffness and immobility, so loss of function.

The other complication, which is a rare subtype, is that sometimes polymyalgia rheumatica can progress to inflammatory arthritis, where the joints also start getting inflamed. Thus, inflammation not just around the shoulders and the thighs, but also in the fingers and toes, becoming something like rheumatoid arthritis.

In addition, some patients with polymyalgia rheumatica can also progress to develop a condition called temporal arteritis, which is inflammation of the blood vessels, particularly the ones around the head and around the eye. It's a sister diagnosis to polymyalgia rheumatica, so it doesn't happen to all patients. However, it's very important that this is recognised early as this counts as an emergency if it does develop.

What tests are used to detect and diagnose polymyalgia rheumatica?

Polymyalgia rheumatica is diagnosed predominantly based on the history of stiffness in the areas that I've mentioned, together with an examination that confirms the evidence this brings into the diagnosis.

To support the diagnosis, I often request blood tests, and these would check the inflammation markers. The blood test will show signs of inflammation and, rarely, we look for complications if suspected. For example, if a patient is struggling for a long time and there are other symptoms elsewhere, such as changing bowel habits or respiratory symptoms, then we may look at investigating these separately as well.

What treatment options are available for polymyalgia rheumatica, and how long does treatment typically last?

The good news about polymyalgia rheumatica is that it’s exquisitely responsive to steroid treatment. Steroids are the main focus treatment option for this condition.

In general, we start on a relatively low dose, around 12.5 to 15 milligrams of steroid, and the expectation is that patients should feel much better within 48 hours to 5 days. As a rule of thumb, if patients don't respond or don't feel better with steroids, then probably the diagnosis is wrong and we should think about an alternative.

Essentially, polymyalgia rheumatica is a very treatable condition. I suppose, perhaps more complicated though, is that it requires long-term steroid use. In general, it requires a very slow reduction in the amount of steroids that we give. We start off with, for example, 15 milligrams. Over a month, the dose goes down to 10 milligrams, and then every month we reduce it by one milligram or so.

In general, patients tend to require steroids for at least 10 months, but sometimes up to two years. Obviously, this is on a weaning regime, so the dose does decline over time, but it's important to remember that steroids can have multiple side effects, and it's important to try to mitigate these. For example, we often give bone protection with calcium and vitamin D together with the steroids. We also give a stomach protection option to prevent heartburn that often steroids can cause.

How often should I follow up for monitoring and adjustments to my treatment plan?

In general, I tend to follow up patients quite quickly after I start them on steroids. For example, I would arrange a follow up within two weeks to four weeks to make sure that the patient is responding, because as mentioned before, if they're not, then it's important to think about alternative diagnoses and other possible complications.

After that, follow up would be once every three months to six months, just to make sure that the gradual reduction in steroids is effective.

Very rarely, patients may find that they are struggling to bring down their steroid dose down to safer levels and if, for example, they maintain high levels of steroids, I would have to then introduce an alternative medication, which is a long-term immune therapy to help come off the steroids.

Steroids, if taken too long, can cause long-term complications, and this is where we would think about adding in alternative treatments. So, it's important to keep track of things, but in general, patients tend to wean the steroids with no real problems. Over the course of the 10 months to two years, patients come off steroids and the condition doesn’t come back.

To schedule an appointment with Dr Ziad Farah, head on over to his Top Doctors profile today.