Polymyalgia rheumatica

Definition. An inflammatory condition of older adults — essentially never below age 50 — producing pain and morning stiffness of the shoulder and pelvic girdles with a systemic inflammatory response. It causes painful muscles with proximal myopathy and is an important, completely reversible cause of frailty that is often misdiagnosed by clinicians.

Clinical features. Bilateral, symmetrical aching of shoulders, neck and hips; morning stiffness >45 minutes; difficulty rising from a chair, turning in bed or combing the hair. Constitutional features — weight loss, low-grade fever, fatigue, anorexia and depression. Weakness is pain-limited, with preserved true power.

Investigations. Raised ESR and CRP (ESR often >40 mm/h) — the diagnosis is confirmed by finding an elevated ESR in the right clinical setting. Normocytic normochromic anaemia, raised alkaline phosphatase, thrombocytosis. Normal creatine kinase — the key discriminator from inflammatory myopathy. RF and anti-CCP negative. Ultrasound shows subacromial–subdeltoid bursitis, biceps tenosynovitis and trochanteric bursitis.

Differential diagnosis. Elderly-onset rheumatoid arthritis, inflammatory myopathy (polymyositis — CK raised), hypothyroidism, cervical spondylosis and shoulder osteoarthritis, multiple myeloma and occult malignancy, statin-induced myopathy, RS3PE, and other endocrine disorders of insidious onset (hyperthyroidism, hypoadrenalism).

Relationship with giant cell arteritis. There is a close association between PMR and temporal arteritis: about 16–21% of PMR patients develop GCA, and 40–50% of GCA patients have PMR symptoms. Any symptom suggesting temporal artery involvement — headache, jaw claudication, scalp tenderness or a recent change in vision — especially with a very high ESR (>75 mm/h), should prompt consideration of temporal artery biopsy. Acute treatment of temporal arteritis with high-dose steroids is needed to prevent blindness.

Treatment. Prednisolone 12.5–25 mg daily produces a dramatic response within 24–72 hours — a poor response should make you doubt the diagnosis. Taper slowly over 1–2 years. Methotrexate is used as a corticosteroid-sparing agent for frequent relapses or steroid toxicity; infliximab has NOT been shown to be beneficial and is not recommended. Mandatory alongside steroids: calcium, vitamin D and a bisphosphonate, glucose and blood-pressure monitoring, gastroprotection, and a steroid alert card.

The 2025/2026 EULAR recommendations for PMR and primary large-vessel vasculitis now name sarilumab (IL-6 receptor blocker, 200 mg subcutaneously every 2 weeks) as the preferred add-on for relapsing or refractory PMR, with tocilizumab as an alternative and methotrexate retained as a cheaper option — a glucocorticoid taper as rapid as 14 weeks is possible on sarilumab. For GCA, suspected cases must be referred within 24 hours, and adjunctive tocilizumab or upadacitinib 15 mg once daily is recommended for refractory/relapsing disease or where the risk of steroid toxicity is high (upadacitinib FDA-approved April 2025 on the SELECT-GCA trial: sustained remission 46% vs 29% with placebo, with roughly halved cumulative steroid exposure).

taper over 1–2 years · sarilumab 200 mg SC 2-weekly · upadacitinib 15 mg OD.