Polymyalgia rheumatica M35.3

Bruce 1888

Etiologically unexplained inflammatory disease of the connective tissue and the musculature with strong painfulness of the musculature, especially pelvic and shoulder girdle pain such as sore muscles and associated morning stiffness (usually >1h), feeling of illness and weight loss, night sweat, increased BSG (>40mm/h) and/or symptoms of depression.

Polymyalgia rheumatica develops in close association with giant cell arteritis (association in 50-80% of cases) or it is considered its minus variant. The disease can also occur as a paraneoplastic syndrome.

Incidence in persons > 50 years (Federal Republic of Germany): 300-700/100,000 inhabitants/year.

Mostly after the 50th LJ and predominantly occurring in women.

Remember! Characteristic triad: muscular pain, fall reduction (at least 40 mm/hour), anaemia.

Persistent pain for at least 4 weeks with morning stiffness in the neck, shoulder girdle (70-95%) or pelvic girdle (50-70%), usually lasting > 60 minutes. Oedema on the extensor sides of the extremities (back of the hand, back of the foot) and subdeltoidal bursitis are common.

Often associated (20% of cases) is giant cell arteritis (arteritis cranialis).

Polymyalgia rheumatica: ACR/EULAR classification criteria (2012)

Inclusion criteria: =/> 50 years, new shoulder girdle pain on both sides, CFP and/or BSG increased. Additionally:

• Morning stiffness =/>45 min (2 points)
• Absence of rheumatoid factor CCP (2 points)
• Pain/stiffness pelvic girdle (1 point)
• Absence of other joint manifestations (1 point)

Plus sonography:

• 1 shoulder joint+1 hip joint (1 point)
• Both shoulder joints (1 point)

A score of =/>5 points has a sensitivity and specificity 70% for the diagnosis PMR.

Early glucocorticoids such as prednisone (e.g. Decortin) initially 15-20 mg/day p.o. Gradual reduction after 14 days, maintenance dose over 1-2 years at 5-10 mg/day p.o. (rule of thumb: continue therapy for at least 1 year beyond freedom from symptoms).

Note: Higher doses should not be used: risk of recurrence is increased, danger of masking giant cell arteritis.

If glucocorticoid monotherapy fails, try additional administration of methotre1xate (10 to 20 mg/week). Non-steroidal anti-inflammatory drugs are only slightly pain-relieving.

Low-dose ASA (100 mg/day) prevents ischemic complications in the case of possibly associated giant cell arteritis.

Osteoporosis prophylaxis: oestrogen-progestogen substitution, e.g. Estraderm TTS = 17-β-oestradiol with a daily dose of 0.05 mg combined with progestogen (e.g. Kliogest N). Continuous use after the menopause.

Adequate supply of calcium and vitamin D (e.g. Frubiase Calcium forte, Ossofortin).

In refractory cases: cyclophosphamide; alternatively: tocilizumab.

In the case of biopsy-proven giant cell arteritis in the event of complications (deterioration in visual acuity), higher doses of glucocorticoids (initially 100-500 mg/day i.v. with gradual dose reduction).

Remember! Always looking for tumors!

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