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POLYMYALGIA RHEUMATICA

Polymyalgia Rheumatica (PMR) causes stiffness and aching of the muscles about the neck, shoulders, and hips. Most people with PMR have symptoms in at least two of these three areas. The shoulder region includes the muscles of the upper arm. The hip region includes the muscles of the lower back and thighs.

What is it?

Polymyalgia rheumatica (PMR) is a disorder that causes stiffness and aching that begins in the neck, shoulder, and hip areas. It is not known whether it is a disease of the joints, muscles, or arteries. However, it is thought that inflammation in these areas leads to pain and stiffness.

Incidence and risk factors

Polymyalgia rheumatica typically affects people in the 60s and 70s. It is rare before age 50. It affects people of Northern European ancestry particularly those from Scandinavia. It is rare among people of African ancestry. PMR does not have strong hereditary tendencies.

In most cases, the symptoms start very suddenly. People with PMR may be perfectly well one day and then feel the full effects of this disease the next day. Sometimes the symptoms come more slowly. Stiffness is a major feature of PMR. It often is worse first thing in the morning. When it is severe, you may have difficulty getting out of bed. Pain may wake you at night, and turning over in bed may be difficult. The stiffness may be worse during periods of inactivity, such as after a long car ride.

PMR also may cause other symptoms. These include fatigue, weight loss, and a slight fever. Some people may experience depression in their attempt to cope with this disorder. Joints in other areas of the body may ache as well. Sometimes joints in the hands swell. Numbness and tingling in the fingers (carpal tunnel syndrome) also may occur with PMR.

Most persons with this disease have been in very good health before their first symptoms. People often do not understand why they feel so terrible when the disease begins. These symptoms usually make them feel very different than before and can be quite overwhelming because of their effect on everyday life. PMR usually is not associated with any other disease. However, a person with PMR also may develop other forms of arthritis. Some people with PMR also have a condition called giant cell arteritis, which is described below.

Diagnosis

PMR is a syndrome. A syndrome is a collection of symptoms. There is no single test that can be used to make the diagnosis. This can make the diagnosis of PMR difficult. To make the diagnosis, your doctor will consider your symptoms along with results of y our physical examination and laboratory tests. Other rheumatic diseases, infections, and cancer can cause symptoms similar to PMR. It can take a while to finally make the diagnosis of PMR. To find out if you have PMR, your doctor will:

  • ask about your symptoms and recent changes in your health
  • perform a physical examination
  • obtain certain blood tests

These blood tests will be used to check for diseases that cause symptoms similar to PMR. A blood test called the erythrocyte sedimentation rate (or sed rate) will likely be included. The sed rate can measure the amount of inflammation present. This test measures how fast red blood cells cling together, fall, and settle toward the bottom of a glass tube in an hour’s time, like sediment. When inflammation is present, the red blood cells sink more quickly and the sed rate is higher than normal. As inflammation responds to medication, the sed rate usually goes down. In almost all persons with PMR, the sed rate is higher than normal. However, the sed rate is higher than normal in other diseases besides PMR. As a result, the diagnosis of PMR cannot be made by blood test alone because the blood test cannot distinguish PMR from other conditions such as infection or other forms of arthritis.

Other special tests may be necessary. This additional testing will depend on your symptoms as well as what your doctor finds by examining you. In the process of diagnosing PMR and separating it from other conditions, it sometimes is necessary to do a biopsy of a blood vessel. To do a biopsy, a doctor takes a small piece of tissue to examine under a microscope.

Treatment

The goal in treating PMR is to help relieve pain, stiffness, and achiness. Treatment includes medications to help reduce inflammation as well as proper exercise and rest for some people in order to maintain joint flexibility, muscle strength, and function.

Medication

The two groups of medicines used most often to treat PMR are corticosteroids, which are cortisone-like drugs, and nonsteroidal antiinflammatory drugs. Corticosteroid drugs are strong medications that help reduce inflammation. They also help relieve stiffness and achiness. They act quickly in PMR. Most people feel better within a few days or sometimes even the next day. There are many forms of corticosteroids (for example, prednisone often used in PMR).

If your doctor places you on a corticosteroid, you should follow instructions carefully. Your doctor may either have you take the entire dose in the morning or have you divide the dose throughout the day. You probably will feel better very soon after starting this medicine. I t is important to keep taking the medicine even though you are feeling better. PMR can return if you stop this medicine too quickly.

You may need to take corticosteroids as briefly as six months or as long as one or two years. Some people may need to be treated even longer. As you improve while on this medicine, it is likely that the dose will slowly be decreased. Follow your doctor’s instructions on how often to take your medication. Do not try to cut back the dose on your own or suddenly stop taking your medication, since your symptoms can worsen. Over a long time, corticosteroids may cause such side effects as:

  • Weight gain
  • Thinning of the bones (osteoporosis)
  • Depression and mood swings
  • Increased risk of infection
  • Cataracts
  • Glaucoma
  • Worsening of diabetes or new diabetes in someone who has never had it
  • Thinning of the skin and easy bruising
  • Rounding of the face
  • Difficulty sleeping
  • High blood pressure (hypertension)

These medications affect everyone differently. You may have some of these side effects or none at all. If they do occur, most of these side effects will go away when the medication is stopped or decreased. Your doctor can give you some helpful tips about diet and exercise to help with some of the side effects. If you are placed on this medication, it is because your doctor feels that your symptoms are serious enough to need this medication. Be sure to discuss any concerns that you have about this medicine with your doctor. Also let your doctor know about any side effects that you may be experiencing. For more information about corticosteroids, contact your local Arthritis Foundation chapter and request their brochure entitled “Corticosteroids.”

Special Instructions for Corticosteroids
Corticosteroids are different from many of the medications you may have taken in the past. Your body naturally produces small amounts of hormones that are forms of corticosteroids. When you take corticosteroids for more than a few days, your body may stop producing some of these hormones. This is not permanent. Your body gradually will start making the hormones again as the dose of your medication is lowered.

Your body depends on corticosteroids for many daily functions. These hormones are important during times of stress. Your body does not care whether it receives corticosteroids from natural hormones or from medication. However, if you suddenly stop taking this medication, your body may not make enough hormones on its own on short notice. This can make you seriously ill. Also, your body’s need for this medicine is greatest in the morning. That is one reason why most people should take some or all of the medicine in the morning.

Some important rules about corticosteroids are as follows:

  • Do not stop this medication without discussing it with your doctor.
  • Do not try to decrease this medication on your own. You and your doctor will need to work together to gradually wean you off of this medicine.
  • Tell your other doctors and other health professionals that you are taking this medicine. Your medication may need to be increased for short periods of time if your body is under a lot of stress-for example, if you are recovering from surgery or a serious illness. Even after you have been off corticosteroids for as long a one-year, you should tell your doctor that you used to take them.
  • Wear medical identification to let people know that you take these medications in case a medical emergency occurs. Should you be involved in an accident or become seriously ill, it is very important that this information be known. Also, tell your family that you are taking corticosteroids so they can tell others in an emergency.
  • If you become ill and are unable to take this medication because of vomiting, let your doctor know right away. You may need to increase your usual dose for several days when you are sick.

Many of the side effects of corticosteroids are directly related to the dose given. The therapeutic goal is to always find the lowest effective dose that will avoid as many of the side effects as possible. You probably will not need large doses of corticosteroids unless your PMR is accompanied by giant cell arteritis (see below). Serious side effects are much less common with the low doses of corticosteroids usually used in PMR, but it still is wise to follow safety rules.

Special Instructions for NSAIDs

In addition to corticosteroids, there is a second group of drugs used to treat PMR. These drugs are called nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs are a group of drugs that relieve pain and inflammation. They can help relieve some of the stiffness and achiness of PMR. NSAIDs are not as strong as corticosteroids. Sometimes, very mild cases of PMR can be treated with NSAIDs alone.

Aspirin and ibuprofen are two examples of NSAIDs. Other NSAIDs are available by prescription. If you are taking these drugs, be sure to follow your doctor’s instructions. NSAIDs have the potential for some side effects. Guidelines are as follows:

  • Always take NSAIDs with food, since they can upset your stomach and cause ulcers and bleeding.
  • Call your doctor if an NSAID causes indigestion (upset stomach).
  • Do not take more of an NSAID than your doctor prescribes.
  • Do not take additional over-the-counter medications that contain aspirin or ibuprofen in addition to prescribed NSAIDs. Discuss with your doctor whether you can take acetaminophen if you need something extra for pain.

Exercise and Rest
Both exercise and rest play an important role in your treatment. Exercise helps you maintain or regain your energy and muscle strength. Exercise also helps you fight the weight gain and osteoporosis (bone thinning) that can be side effects of taking corticosteroids.

When exercising, it is important to use common sense and to not overdo it. If you are overactive, your symptoms may worsen. Gradually increase the amount of exercise that you do. Good forms of exercise include walking, riding an exercise bicycle, and exercising in a pool. Ask your doctor or PT for specific types of exercise that would be best for you. It also is important to get an adequate amount of rest. You need enough rest to give your body time to recover.

You’ll need to see your doctor regularly once you start taking medication. Tell your doctor how the medicine has affected your symptoms. Report any side effects that you may have developed, such as weight gain or depression. Your doctor may use various tests like the sed rate to adjust your medication. Even though you may feel well, it is important to see your doctor regularly so you can be checked for any signs of a relapse.

Once you have responded to corticosteroids, the goal is to slowly reduce the dose to the lowest level necessary to control symptoms and prevent a relapse. This goal requires that both you and your doctor communicate honestly and completely about your treatment and its effects. Effective treatment allows most people with PMR to lead active and productive lives.

Giant Cell Arteritis

Giant cell arteritis, or GCA, is a condition in which certain arteries (blood vessels) in the body become inflamed. It can develop in some people with PMR. These two diseases often occur together. About 10-15 percent of people with PMR also have GCA. Almost 40 percent of people with GCA also have PMR. However, GCA can occur on its own without PMR. Like PMR, the cause of GCA is unknown.

Giant cell arteritis usually affects areas near the temples on the upper front sides of the head. It also involves other arteries in the head, neck, arms, and, occasionally, will affect other arteries in the body. Inflammation causes the artery to become narrow or blocked. Inflammation can cause further problems with little blood is getting through. The symptoms include:

  • Pain in the jaw muscles when eating or talking
  • Severe headaches
  • Loss of vision, blurry vision or double vision-the vision loss often is described as having a curtain pulled partly over one’s eye
  • Tenderness of the scalp or temples
  • Difficulty hearing
  • Persistent sore throat or difficulty swallowing
  • Cough

Giant cell arteritis may be an especially difficult condition to diagnose in some people who never get head or neck symptoms. These people just have fever, fatigue, weight loss, or anemia.

Loss of vision can be temporary or permanent. It may improve or cause blindness. If you have PMR and start having vision problems, call your doctor immediately. Also tell your doctor if you develop any of the other symptoms. It is important to diagnose and treat giant cell arteritis early to prevent blindness.

Your doctor may need to remove a small piece of an artery above and in front of your ear to determine if you have giant cell arteritis. Often the artery will be taken from the temple through a small incision. You will not need to be put to sleep to do this, but you will receive medicine to numb the area. The piece of the artery then will be examined under a microscope. The artery will be inflamed if you have giant cell arteritis. A sed rate reading also can help determine the diagnosis because, as in the case of PMR, the sed rate is almost always higher than normal.
Corticosteroid drugs are used to treat giant cell arteritis. Higher doses are required to treat giant cell arteritis than to treat PMR. Other medications are available if side effects from the corticosteroids become a problem. You can expect to stay on this treatment for many months to several years, but the dose will be lowered over time once symptoms are controlled.

Both PMR and giant cell arteritis usually will last one to two years. How long these conditions will stay in an individual case can vary quite a bit. Sometimes these diseases recur even if you have been doing well for some time.

Treatment allows most people with these diseases to lead active and productive lives. Most people are able to take lower doses of the medication after they have been treated for a while. Many people eventually are able to stop taking the medication after one or two years, but the threat of relapse requires close communication with your doctor.

 

 

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