Review

Polymyalgia rheumatica: An updated review

Salman Bin Mahmood, MBBS, Elizabeth Nelson, MD, Jessica Padniewski, DO and Rawad Nasr, MD
Cleveland Clinic Journal of Medicine September 2020, 87 (9) 549-556; DOI: https://doi.org/10.3949/ccjm.87a.20008

ABSTRACT

Polymyalgia rheumatica should be suspected in older patients with bilateral shoulder and hip stiffness that is worse in the morning and improves with use. An array of nonspecific musculoskeletal complaints, constitutional symptoms, and elevated serum inflammatory markers may be present, so other conditions should also be considered. Prolonged glucocorticoids with patient-tailored dosing and duration are the mainstay of treatment. Corticosteroid-sparing therapy with adjunctive methotrexate may benefit select patients.

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REFERENCES

  1. ↵
    1. Raheel S,
    2. Shbeeb I,
    3. Crowson CS,
    4. Matteson EL
    . Epidemiology of polymyalgia rheumatica 2000–2014 and examination of incidence and survival trends over 45 years: a population-based study. Arthritis Care Res (Hoboken) 2017; 69(8):1282–1285. doi:10.1002/acr.23132
    OpenUrlCrossRef
  2. ↵
    1. Salvarani C,
    2. Macchioni P,
    3. Zizzi F, et al
    . Epidemiologic and immunogenetic aspects of polymyalgia rheumatica and giant cell arteritis in northern Italy. Arthritis Rheum 1991;34(3):351–356. doi:10.1002/art.1780340313
    OpenUrlCrossRefPubMed
  3. ↵
    1. González-Gay MA,
    2. Amoli MM,
    3. Garcia-Porrua C,
    4. Ollier WE
    . Genetic markers of disease susceptibility and severity in giant cell arteritis and polymyalgia rheumatica. Semin Arthritis Rheum 2003; 33(1):38–48. doi:10.1053/sarh.2002.50025
    OpenUrlCrossRefPubMed
  4. ↵
    1. González-Gay MA,
    2. Matteson EL,
    3. Castañeda S
    . Polymyalgia rheumatica. Lancet 2017; 390(10103):1700–1712. doi:10.1016/S0140-6736(17)31825-1
    OpenUrlCrossRef
  5. ↵
    1. Chuang TY,
    2. Hunder GG,
    3. Ilstrup DM,
    4. Kurland LT
    . Polymyalgia rheumatica: a 10-year epidemiologic and clinical study. Ann Intern Med 1982; 97(5):672–680. doi:10.7326/0003-4819-97-5-672
    OpenUrlCrossRefPubMed
  6. ↵
    1. Kermani TA,
    2. Warrington KJ
    . Polymyalgia rheumatica. Lancet 2013; 381(9860):63–72. doi:10.1016/S0140-6736(12)60680-1
    OpenUrlCrossRefPubMed
  7. ↵
    1. Gonzalez-Gay MA,
    2. Garcia-Porrua C,
    3. Salvarani C,
    4. Hunder GG
    . Diagnostic approach in a patient presenting with polymyalgia. Clin Exp Rheumatol 1999; 17(3):276–278. pmid:10410257
    OpenUrlPubMed
  8. ↵
    1. Dasgupta B,
    2. Cimmino MA,
    3. Kremers HM, et al
    . 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum 2012;64(4):943–954. doi:10.1002/art.34356
    OpenUrlCrossRefPubMed
  9. ↵
    1. Salvarani C,
    2. Cantini F,
    3. Boiardi L,
    4. Hunder GG
    . Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med 2002; 347(4):261–271. doi:10.1056/NEJMra011913
    OpenUrlCrossRefPubMed
  10. ↵
    1. Bijlsma JWJ,
    2. Hachulla E
    1. Masson C,
    2. Gonzalez-Gay MA
    . Polymyalgia rheumatica and giant cell arteritis. In: Bijlsma JWJ, Hachulla E, eds. EULAR Textbook on Rheumatic Diseases. 2nd ed. London, UK: BMJ Publishing Group; 2015:754–778.
  11. ↵
    1. Gonzalez-Gay MA,
    2. Garcia-Porrua C,
    3. Amor-Dorado JC,
    4. Llorca J
    . Fever in biopsy-proven giant cell arteritis: clinical implications in a defined population. Arthritis Rheum 2004; 51(4):652–655. doi:10.1002/art.20523
    OpenUrlCrossRefPubMed
  12. ↵
    1. González-Gay MA,
    2. Rodríguez-Valverde V,
    3. Blanco R, et al
    . Polymyalgia rheumatica without significantly increased erythrocyte sedimentation rate. A more benign syndrome. Arch Intern Med 1997;157(3):317–320. doi:10.1001/archinte.1997.00440240081012
    OpenUrlCrossRefPubMed
  13. ↵
    1. Jones JG,
    2. Hazleman BL
    . Prognosis and management of polymyalgia rheumatica. Ann Rheum Dis 1981; 40(1):1–5. doi:10.1136/ard.40.1.1
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Weyand CM,
    2. Goronzy JJ
    . Giant-cell arteritis and polymyalgia rheumatica. Ann Intern Med 2003;139(6):505–515. doi:10.7326/0003-4819-139-6-200309160-00015
    OpenUrlCrossRefPubMed
  15. ↵
    1. Salvarani C,
    2. Macchioni PL,
    3. Tartoni PL, et al
    . Polymyalgia rheumatica and giant cell arteritis: a 5-year epidemiologic and clinical study in Reggio Emilia, Italy. Clin Exp Rheumatol 1987;5(3):205–215. pmid:3501353
    OpenUrlPubMed
  16. ↵
    1. Salvarani C,
    2. Gabriel S,
    3. Hunder GG
    . Distal extremity swelling with pitting edema in polymyalgia rheumatica. Report on nineteen cases. Arthritis Rheum 1996;39(1):73–80. doi:10.1002/art.1780390110
    OpenUrlCrossRefPubMed
  17. ↵
    1. Agarwal V,
    2. Dabra AK,
    3. Kaur R,
    4. Sachdev A,
    5. Singh R
    . Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome: ultrasonography as a diagnostic tool. Clin Rheumatol 2005;24(5):476–479. doi:10.1007/s10067-004-1061-x
    OpenUrlCrossRefPubMed
  18. ↵
    1. McCarty DJ,
    2. O’Duffy JD,
    3. Pearson L,
    4. Hunter JB
    . Remitting seronegative symmetrical synovitis with pitting edema. RS3PE syndrome. JAMA 1985;254(19):2763–2767. pmid:4057484
    OpenUrlCrossRefPubMed
  19. ↵
    1. Yao Q,
    2. Su X,
    3. Altman RD
    . Is remitting seronegative symmetrical synovitis with pitting edema (RS3PE) a subset of rheumatoid arthritis? Semin Arthritis Rheum 2010;40(1):89–94. doi:10.1016/j.semarthrit.2008.11.006
    OpenUrlCrossRefPubMed
  20. ↵
    1. Gonzalez-Gay MA
    . Giant cell arteritis and polymyalgia rheumatica: two different but often overlapping conditions. Semin Arthritis Rheum 2004;33(5):289–293. doi:10.1016/j.semarthrit.2003.09.007
    OpenUrlCrossRefPubMed
  21. ↵
    1. Salvarani C,
    2. Gabriel SE,
    3. O’Fallon WM,
    4. Hunder GG
    . The incidence of giant cell arteritis in Olmsted County, Minnesota: apparent fluctuations in a cyclic pattern. Ann Intern Med 1995;123(3):192–194. doi:10.7326/0003-4819-123-3-199508010-00006
    OpenUrlCrossRefPubMed
  22. ↵
    1. González-Gay MA,
    2. Amoli MM,
    3. Garcia-Porrua C,
    4. Ollier WE
    . Genetic markers of disease susceptibility and severity in giant cell arteritis and polymyalgia rheumatica. Semin Arthritis Rheum 2003; 33(1):38–48. doi:10.1053/sarh.2002.50025
    OpenUrlCrossRefPubMed
  23. ↵
    1. Ward NC,
    2. Watts GF,
    3. Eckel RH
    . Statin toxicity. Circ Res 2019;124(2):328–350. doi:10.1161/CIRCRESAHA.118.312782
    OpenUrlCrossRef
  24. ↵
    1. Selva-O’Callaghan A,
    2. Alvarado-Cardenas M,
    3. Pinal-Fernández I, et al
    . Statin-induced myalgia and myositis: an update on pathogenesis and clinical recommendations. Expert Rev Clin Immunol 2018;14(3):215–224. doi:10.1080/1744666X.2018.1440206
    OpenUrlCrossRef
  25. ↵
    1. Mackie SL,
    2. Koduri G,
    3. Hill CL, et al
    . Accuracy of musculoskeletal imaging for the diagnosis of polymyalgia rheumatica: systematic review. RMD Open 2015; 1(1):e000100. doi:10.1136/rmdopen-2015-000100
    OpenUrlCrossRefPubMed
  26. ↵
    1. Macchioni P,
    2. Boiardi L,
    3. Catanoso M,
    4. Pazzola G,
    5. Salvarani C
    . Performance of the new 2012 EULAR/ACR classification criteria for polymyalgia rheumatica: comparison with the previous criteria in a single-centre study. Ann Rheum Dis 2014;73(6):1190–1193. doi:10.1136/annrheumdis-2013-204167
    OpenUrlAbstract/FREE Full Text
  27. ↵
    1. Newman JS,
    2. Laing TJ,
    3. McCarthy CJ,
    4. Adler RS
    . Power Doppler sonography of synovitis: assessment of therapeutic response—preliminary observations. Radiology 1996;198(2):582–584. doi:10.1148/radiology.198.2.8596870
    OpenUrlCrossRefPubMed
  28. ↵
    1. Macchioni P,
    2. Catanoso MG,
    3. Pipitone N,
    4. Boiardi L,
    5. Salvarani C
    . Longitudinal examination with shoulder ultrasound of patients with polymyalgia rheumatica. Rheumatology (Oxford) 2009; 48(12):1566–1569. doi:10.1093/rheumatology/kep286
    OpenUrlCrossRefPubMed
  29. ↵
    1. Gonzalez-Gay MA,
    2. Agudo M,
    3. Martinez-Dubois C,
    4. Pompei O,
    5. Blanco R
    . Medical management of polymyalgia rheumatica. Expert Opin Pharmacother 2010;11(7):1077–1087. doi:10.1517/14656561003724739
    OpenUrlCrossRefPubMed
  30. ↵
    1. Dejaco C,
    2. Singh YP,
    3. Perel P, et al; European League Against Rheumatism; American College of Rheumatology
    . 2015 Recommenda tions for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2015;74(10):1799–1807. doi:10.1136/annrheumdis-2015-207492
    OpenUrlAbstract/FREE Full Text
  31. ↵
    1. Kyle V,
    2. Hazleman BL
    . Treatment of polymyalgia rheumatica and giant cell arteritis. II. Relation between steroid dose and steroid associated side effects. Ann Rheum Dis 1989; 48(8):662–666. doi:10.1136/ard.48.8.662
    OpenUrlAbstract/FREE Full Text
  32. ↵
    1. Kremers HM,
    2. Reinalda MS,
    3. Crowson CS,
    4. Zinsmeister AR,
    5. Hunder GG,
    6. Gabriel SE
    . Relapse in a population based cohort of patients with polymyalgia rheumatica. J Rheumatol 2005; 32(1):65–73. pmid:15630727
    OpenUrlAbstract/FREE Full Text
  33. ↵
    1. Salvarani C,
    2. Cantini F,
    3. Niccoli L, et al
    . Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum 2005;53(1):33–38. doi:10.1002/art.20901
    OpenUrlCrossRefPubMed
  34. ↵
    1. Dasgupta B,
    2. Dolan AL,
    3. Panayi GS,
    4. Fernandes L
    . An initially double-blind controlled 96 week trial of depot methylprednisolone against oral prednisolone in the treatment of polymyalgia rheumatica. Br J Rheumatol 1998; 37(2):189–195. doi:10.1093/rheumatology/37.2.189
    OpenUrlCrossRefPubMed
  35. ↵
    1. Weyand CM,
    2. Goronzy JJ
    . Clinical practice. Giant-cell arteritis and polymyalgia rheumatica. N Engl J Med 2014; 371(1):50–57. doi:10.1056/NEJMcp1214825
    OpenUrlCrossRefPubMed
  36. ↵
    1. Hernández-Rodríguez J,
    2. Cid MC,
    3. López-Soto A,
    4. Espigol-Frigolé G,
    5. Bosch X
    . Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med 2009; 169(20):1839–1850. doi:10.1001/archinternmed.2009.352
    OpenUrlCrossRefPubMed
  37. ↵
    1. Dasgupta B,
    2. Borg F,
    3. Hassan N, et al; BSR and BHPR Standards, Guidelines and Audit Working Group
    . BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology (Oxford) 2010;49(1):186–190. doi:10.1093/rheumatology/kep303a
    OpenUrlCrossRefPubMed
  38. ↵
    Polymyalgia rheumatica: look before you leap. Best Practice J 2013; (53):24–31. Accessed August 16, 2020. https://bpac.org.nz/BPJ/2013/June/docs/BPJ53pages24-31.pdf
  39. ↵
    1. Hoes JN,
    2. Jacobs JW,
    3. Boers M, et al
    . EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2007;66(12):1560–1567. doi:10.1136/ard.2007.072157
    OpenUrlAbstract/FREE Full Text
  40. ↵
    1. Do-Nguyen D,
    2. Inderjeeth CA,
    3. Edelman J,
    4. Cheah P
    . Retrospective analysis of the clinical course of patients treated for polymyalgia. Open Access Rheumatol 2013; 5:33–41. doi:10.2147/OARRR.S38443
    OpenUrlCrossRefPubMed
  41. ↵
    1. van der Veen MJ,
    2. Dinant HJ,
    3. van Booma-Frankfort C,
    4. van Albada-Kuipers GA,
    5. Bijlsma JW
    . Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis? Ann Rheum Dis 1996; 55(4):218–223. doi:10.1136/ard.55.4.218
    OpenUrlAbstract/FREE Full Text
  42. ↵
    1. Caporali R,
    2. Cimmino MA,
    3. Ferraccioli G, et al; Systemic Vasculitis Study Group of the Italian Society for Rheumatology
    . Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2004;141(7):493–500. doi:10.7326/0003-4819-141-7-200410050-00005
    OpenUrlCrossRefPubMed
  43. ↵
    1. Ferraccioli G,
    2. Salaffi F,
    3. De Vita S,
    4. Casatta L,
    5. Bartoli E
    . Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol 1996; 23(4):624–628. pmid:8730115
    OpenUrlPubMed
  44. ↵
    1. De Silva M,
    2. Hazleman BL
    . Azathioprine in giant cell arteritis/polymyalgia rheumatica: a double-blind study. Ann Rheum Dis 1986; 45(2):136–138. doi:10.1136/ard.45.2.136
    OpenUrlAbstract/FREE Full Text
  45. ↵
    1. Aikawa NE,
    2. Pereira RM,
    3. Lage L,
    4. Bonfá E,
    5. Carvalho JF
    . Anti-TNF therapy for polymyalgia rheumatica: report of 99 cases and review of the literature. Clin Rheumatol 2012; 31(3):575–579. doi:10.1007/s10067-011-1914-z
    OpenUrlCrossRefPubMed
  46. ↵
    1. Salvarani C,
    2. Macchioni P,
    3. Manzini C, et al
    . Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial. Ann Intern Med 2007;146(9):631–639. doi:10.7326/0003-4819-146-9-200705010-00005
    OpenUrlCrossRefPubMed
  47. ↵
    1. Kreiner F,
    2. Galbo H
    . Effect of etanercept in polymyalgia rheumatica: a randomized controlled trial. Arthritis Res Ther 2010; 12(5):R176. doi:10.1186/ar3140
    OpenUrlCrossRefPubMed
  48. ↵
    1. Martinez-Taboada VM,
    2. Alvarez L,
    3. RuizSoto M,
    4. Marin-Vidalled MJ,
    5. Lopez-Hoyos M
    . Giant cell arteritis and polymyalgia rheumatica: role of cytokines in the pathogenesis and implications for treatment. Cytokine 2008; 44(2):207–220. doi:10.1016/j.cyto.2008.09.004
    OpenUrlCrossRefPubMed
    1. Cutolo M,
    2. Montecucco CM,
    3. Cavagna L, et al
    . Serum cytokines and steroidal hormones in polymyalgia rheumatica and elderly-onset rheumatoid arthritis. Ann Rheum Dis 2006;65(11):1438–1443. doi:10.1136/ard.2006.051979
    OpenUrlAbstract/FREE Full Text
  50. ↵
    1. Alvarez-Rodriguez L,
    2. Lopez-Hoyos M,
    3. Mata C, et al
    . Circulating cytokines in active polymyalgia rheumatica. Ann Rheum Dis 2010;69(1):263–269. doi:10.1136/ard.2008.103663
    OpenUrlAbstract/FREE Full Text
  51. ↵
    1. Devauchelle-Pensec V,
    2. Berthelot JM,
    3. Cornec D, et al
    . Efficacy of first-line tocilizumab therapy in early polymyalgia rheumatica: a prospective longitudinal study. Ann Rheum Dis 2016;75(8):1506–1510. doi:10.1136/annrheumdis-2015-208742
    OpenUrlAbstract/FREE Full Text
  52. ↵
    1. Lally L,
    2. Forbess L,
    3. Hatzis C,
    4. Spiera R
    . Brief report: a prospective open-label phase IIa trial of tocilizumab in the treatment of polymyalgia rheumatica. Arthritis Rheumatol 2016; 68(10):2550–2554. doi:10.1002/art.39740
    OpenUrlCrossRef
  53. ↵
    1. Izumi K,
    2. Kuda H,
    3. Ushikubo M,
    4. Kuwana M,
    5. Takeuchi T,
    6. Oshima H
    . Tocilizumab is effective against polymyalgia rheumatica: experience in 13 intractable cases. RMD Open 2015; 1(1):e000162. doi:10.1136/rmdopen-2015-000162
    OpenUrlAbstract/FREE Full Text
  54. ↵
    1. US National Library of Medicine
    . Safety and Efficacy of Tocilizumab Versus Placebo in Polymyalgia Rheumatica with Glucocorticoid Dependence (SEMAPHORE). ClinicalTrials.gov Identifier: NCT02908217. https://clinicaltrials.gov/ct2/show/NCT02908217. Accessed July 7, 2020.
  55. ↵
    1. Jones G,
    2. Panova E
    . New insights and long-term safety of tocilizumab in rheumatoid arthritis. Ther Adv Musculoskelet Dis 2018; 10(10):195–199. doi:10.1177/1759720X18798462
    OpenUrlCrossRef
  56. ↵
    1. Nesher G,
    2. Breuer GS
    . Giant cell arteritis and polymyalgia rheumatica: 2016 update. Rambam Maimonides Med J 2016; 7(4). doi:10.5041/RMMJ.10262
    OpenUrlCrossRef
  57. ↵
    1. Charlton R
    . Optimal management of giant cell arteritis and polymyalgia rheumatica. Ther Clin Risk Manag 2012; 8:173–179. doi:10.2147/TCRM.S13088
    OpenUrlCrossRefPubMed
  58. ↵
    1. Gonzalez-Gay MA,
    2. Martinez-Dubois C,
    3. Agudo M,
    4. Pompei O,
    5. Blanco R,
    6. Llorca J
    . Giant cell arteritis: epidemiology, diagnosis, and management. Curr Rheumatol Rep 2010; 12(6):436–442. doi:10.1007/s11926-010-0135-9
    OpenUrlCrossRefPubMed
  59. ↵
    1. Loricera J,
    2. Blanco R,
    3. Hernandez JL, et al
    . Non-infectious aortitis: a report of 32 cases from a single tertiary centre in a 4-year period and literature review. Clin Exp Rheumatol 2015; 33(2 suppl 89): S-19–31. pmid:25437450
    OpenUrlPubMed

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