Dear Dr Makis
I have recently been diagnosed with a condition called polymyalgia rheumatica. The doctor seemed to be in a rush during my consultation and told me to take steroid tablets to make it better. I don’t really understand much about this condition. Can you explain what it is for me?
Mrs Francis
Dear Francis,
Polymyalgia rheumatica, or PMR, is a condition which causes inflammation of large muscles. 'Poly' means many and 'myalgia' means muscle pain. The cause of PMR is not known.PMR mainly affects people over the age of 65. It is rare in people aged under 50. About 1 in 1,000 people over the age of 50 develop PMR each year. Women are three times more likely to be affected than men.
The most common symptoms of PMR are stiffness, pain, aching and tenderness of the large muscles around the shoulders and upper arms. The muscles around the neck and hips may also be affected. The stiffness may be so bad that you may have difficulty turning over in bed, rising from a bed or a chair, or raising your arms above shoulder height (for example, to comb your hair). The stiffness is usually worst first thing in the morning. Getting out of bed may be difficult. The stiffness often eases after an hour or so after getting up from bed and as the day goes on. Inflammation and swelling sometimes occur in other soft tissues of the body. For example, tendons may become inflamed (tenosynovitis), your hands or feet may become slightly swollen and some joints may become slightly swollen.
Other general symptoms may also occasionally occur. These include tiredness, depression, night sweats, high temperature (fever), loss of appetite, and weight loss. Symptoms typically develop over a few days or weeks. However, they develop more slowly in some cases. You may pass it off as aches and pains of getting older when symptoms first start.
Symptoms of PMR are sometimes similar to other conditions such as frozen shoulder, arthritis, or other muscle diseases. So, a blood test is usually done to help make the correct diagnosis. No blood test is 100% reliable for PMR. However, blood tests called the erythrocyte sedimentation rate (ESR) test and the C-reactive protein (CRP) test can detect if there is inflammation in your body from various diseases. If either of these blood tests shows a high level of inflammation and you have the typical symptoms, this usually confirms the diagnosis of PMR.
A steroid medicine such as prednisolone is the usual treatment. Steroids work by reducing swelling (inflammation). Treatment usually works quickly, within a few days. After starting treatment, the improvement in symptoms over 2-3 days is often quite dramatic. In fact, if symptoms do not greatly ease and go within a week or so of treatment then the diagnosis of PMR may not be correct. Tell your doctor if symptoms do not go with steroids, as the symptoms may be due to another disease.
Treatment is usually started with a medium dose - usually about 15 mg per day. This is then reduced gradually to a lower maintenance dose. It may take several months to reduce the dose gradually. The maintenance dose needed to keep symptoms away varies from person to person. Usually, it is between 2.5 and 5 mg per day. You are likely to need treatment for at least one or two years. In some people the condition goes away, so the steroids can be stopped after this time. However, many people need treatment for several years, sometimes for life. If you stop taking the steroid tablets too soon, the symptoms return. Some people are able to stop treatment after 2-3 years but symptoms sometimes return at a later time (a relapse). If this occurs, the treatment with steroids can be restarted and will usually work well again. Your doctor will be able to guide you though how to gradually reduce the dose of the steroid.
Between 1 and 2 in every 10 people with PMR also develop a related condition called giant cell arteritis (GCA) (also known as temporal arteritis). This may be at the same time or some time earlier or later than when PMR develops. GCA can be much more serious than PMR. GCA causes swelling (inflammation) of blood vessels (arteries). The arteries most commonly affected are those which pass over the temples - that is, the sides of the forehead next to the eyes. The eye can be affected in some cases. This can lead to serious eye problems, even total loss of vision. Rarely, other arteries such as those going to the brain are affected. If you develop GCA, you should start treatment as soon as possible after symptoms develop. It is treated with a much higher dose of steroids than PMR. So you can still develop GCA even if you are being treated for PMR. So, tell a doctor immediately if you have PMR and you develop symptoms of headache or tenderness on one side of your head, pain in your jaw when you chew which eases quickly when you rest the jaw muscles, sudden loss of vision, or any other sudden visual problem in one or both eyes or weakness, numbness, deafness or any other nerve-related symptom.
I hope this gives you a little more information about this condition and that you start to feel better soon.
Dr Makis
Dr Makis offers medical advice via his monthly article in the Paphos Post newspaper. If you require personal medical advice, contact your own GP in the first instance. For further information about Veramedica Medical Center, please contact us.