Synopsis
Recognise polymyalgia rheumatica as an inflammatory pain-and-stiffness syndrome in older adults, exclude mimics and coexisting giant-cell arteritis, use a diagnostic glucocorticoid regimen with structured taper, and investigate atypical response.
- PMR causes new bilateral shoulder aching with morning stiffness longer than forty-five minutes in adults over fifty, commonly with hip-girdle pain and raised CRP or ESR.
- Confirm pain-limited movement rather than true weakness; abnormal power, CK, reflexes, sensation, rash or dysphagia requires an alternative neuromuscular assessment.
- Ask about headache, scalp tenderness, jaw claudication, visual symptoms, limb claudication and aortic pain at diagnosis and every follow-up.
- Obtain FBC, CRP, ESR, renal, liver, calcium, ALP, glucose, thyroid and CK, with RF or anti-CCP, protein electrophoresis, imaging and infection tests guided by phenotype.
- Start prednisolone 15 mg orally once daily for a typical uncomplicated presentation after baseline assessment; a substantial clinical response within about one week supports but does not prove diagnosis.
- Maintain 15 mg for three weeks, reduce to 12.5 mg for three weeks, then 10 mg for four to six weeks, followed by reductions of 1 mg every four to eight weeks if remission persists.
- Do not use PMR-dose steroid for possible GCA; suspected cranial disease needs 40–60 mg prednisolone and visual symptoms require an emergency high-dose pathway.
- Relapse means recurrent PMR symptoms with a supportive marker rise after alternatives are assessed; return to the previous effective dose and taper again rather than restarting the entire schedule automatically.
- Consider methotrexate early in repeated relapse, prolonged treatment or high steroid-toxicity risk with rheumatology monitoring.
- Poor or incomplete response should trigger diagnostic review for GCA, RA, myositis, infection, malignancy and structural shoulder disease rather than repeated empirical steroid increases.
Key red flags
Any visual symptom, jaw claudication or new cranial pain requires immediate GCA assessment before routine PMR review.
Objective muscle weakness, dysphagia, rash or markedly raised CK suggests inflammatory myopathy rather than uncomplicated PMR.
Fever, night sweats, focal pain, lymphadenopathy, weight loss or poor steroid response requires infection and malignancy assessment.
Peripheral synovitis, erosions or persistent small-joint swelling may indicate elderly-onset rheumatoid arthritis.
Relapse symptoms with low blood pressure, vomiting or severe weakness during rapid taper may represent adrenal insufficiency.
Headache, scalp pain, jaw claudication or any visual symptom changes treatment immediately to the GCA pathway.
Investigation priorities
Support inflammatory activity, identify anaemia or thrombocytosis and create a taper baseline.
Management branches
An adult over fifty has new bilateral girdle pain and prolonged morning stiffness.
- Document stiffness, function, systemic, cranial and visual symptoms and examine temporal arteries, pulses, joints, shoulder mechanics and true muscle power.
- Obtain inflammatory, blood, metabolic, thyroid and muscle tests and add RA, paraprotein, infection or imaging assessment from atypical features.
- If the phenotype is typical and GCA is absent, start prednisolone 15 mg/day and arrange clinical and marker review within one to two weeks.
Symptoms improve substantially and inflammatory markers normalise or return toward baseline.
- Continue 15 mg for three weeks, then 12.5 mg for three weeks and 10 mg for four to six weeks.
- Below 10 mg reduce by 1 mg every four to eight weeks while symptoms and markers remain controlled, individualising for relapse and toxicity.
- At each step screen GCA and record bone, glucose, pressure, infection, eye, mood and adrenal risks.