PMR & Giant Cell Arteritis

Polymyalgia rheumatica:

• •Bilateral shoulder and pelvic girdle pain and stiffness; shoulders involved in >95%, hip girdle in ~50-70%. Pain is aching, deep, and may radiate to upper arms, neck, buttocks, and thighs.
• •Morning stiffness over 45 minutes (often hours); difficulty getting out of bed, dressing, or rising from a chair.
• •Rapid onset over days to weeks; patients can often date the onset precisely.
• •Constitutional features: fatigue (often prominent), malaise, low-grade fever, weight loss, anorexia.
• •Age over 50 (almost always); peak 70-80.
• •No true muscle weakness: movement is pain-limited, not weakness-limited. CK is normal. Genuine proximal weakness with elevated CK is inflammatory myopathy, not PMR.
• •Persistent small-joint synovitis (MCP, PIP, MTP) strongly suggests an alternative or overlapping diagnosis, especially elderly-onset RA.

The steroid response is supportive but not diagnostic in isolation. Per NICE CKS, a working diagnosis is supported by 70% or more patient-reported global improvement within 1 week and normalisation of inflammatory markers within 4 weeks; an absent or minimal response should prompt reconsideration. The 2012 EULAR/ACR PMR classification criteria include age over 50, bilateral shoulder pain, morning stiffness over 45 minutes, raised CRP/ESR, absence of RF/anti-CCP, and absence of other joint involvement; ultrasound findings increase the score.

Giant cell arteritis:

• •New-onset headache (~75%): temporal, different from previous headaches, with scalp tenderness on examination.
• •Jaw claudication is the most specific symptom: masseter pain with sustained chewing, relieved by rest. Distinguish from TMJ dysfunction (mechanical, clicking, no systemic features) by the ischaemic pattern in an older adult with raised markers.
• •Visual symptoms - the most feared complication: amaurosis fugax is a warning sign requiring immediate treatment; AION causes sudden, painless, irreversible monocular visual loss with the contralateral eye at imminent risk.
• •Temporal artery: tender, thickened, nodular, non-pulsatile, with absent pulse.
• •Systemic: fever (a classic cause of PUO in older adults), weight loss, night sweats.
• •PMR features in ~50%.
• •Large-vessel GCA: limb claudication (upper greater than lower), BP discrepancy between arms (>15 mmHg), bruits, absent pulses, aortic regurgitation. May present without cranial symptoms.

Screen PMR patients for GCA at every review - any new headache, jaw claudication, scalp or tongue claudication, or visual disturbance triggers immediate steroid escalation and urgent specialist assessment.

Common mimics: bilateral rotator cuff disease (mechanical, normal markers), elderly-onset RA (small-joint synovitis, RF/anti-CCP), inflammatory myopathy (raised CK, true weakness), CPPD crowned dens syndrome (peri-odontoid calcification on CT), hypothyroidism, and statin-related myalgia.

PMR is a clinical diagnosis. GCA requires immediate treatment on clinical suspicion - investigations confirm but must NEVER delay treatment.

Blood tests:

• •ESR: usually raised in PMR, often markedly raised in GCA (frequently >50, often >100). Around 4-5% of biopsy-proven GCA has normal markers.
• •CRP: often more sensitive than ESR for early monitoring. ESR + CRP together provide the best assessment.
• •FBC: normocytic, normochromic anaemia and thrombocytosis are common.
• •LFTs: raised ALP in ~20-30% (non-specific but supportive).
• •CK: normal in PMR - the key distinction from inflammatory myopathy.
• •TFTs, RF/anti-CCP (if peripheral synovitis is present), renal function, glucose, and bone profile are baseline checks before long-term steroids.

Imaging for GCA:

• •Vascular ultrasound of the temporal and axillary arteries is increasingly first-line in UK fast-track pathways. The halo sign (hypoechoic circumferential wall thickening) and the non-compressible artery sign are characteristic; axillary involvement screens for large-vessel disease. Ultrasound should be performed within days of starting steroids before the halo fades. The 2022 ACR/EULAR GCA classification criteria give imaging significant weight, and biopsy is no longer required in every case.
• •Temporal artery biopsy: granulomatous inflammation with multinucleated giant cells, intimal hyperplasia, and disruption of the internal elastic lamina. Perform within 2 weeks of starting steroids. A specimen of at least 1 cm is recommended because skip lesions mean a negative biopsy does not exclude GCA.
• •CT or MR angiography and PET-CT for large-vessel GCA: vessel wall thickening, stenosis, aneurysm; PET-CT detects active large-vessel inflammation.

Imaging for PMR: ultrasound of the shoulders demonstrating bilateral subacromial bursitis and biceps tenosynovitis supports the 2012 EULAR/ACR provisional classification criteria but is not routinely required when the clinical picture and steroid response are typical.

PMR (NICE CKS and BSR/BHPR taper schedule):

• •Initial prednisolone 15 mg daily (range 15-20 mg). Symptoms usually improve within days. A working diagnosis is supported by 70% or more improvement within 1 week and normalisation of markers within 4 weeks. Absent response means reconsider the diagnosis; for incomplete response, consider 20 mg before concluding the diagnosis is wrong.
• •Slow taper guided by symptoms and inflammatory markers: typical schedule 15 mg for 3 weeks, then 12.5 mg, then 10 mg, then reduce by 1 mg every 4-8 weeks. Typical duration 1-2 years (often longer). Around 50% relapse during taper.
• •Relapse: return to the last effective dose, then resume slower taper. Frequent relapses or inability to taper below 7.5 mg should prompt diagnostic review and consideration of methotrexate as steroid-sparing (once weekly, with folic acid - daily methotrexate is a fatal error).

GCA (BSR 2020 and NICE CKS):

• •Start steroids IMMEDIATELY on clinical suspicion - do NOT wait for investigations.
• •Without visual symptoms: prednisolone 40-60 mg daily.
• •With visual symptoms or jaw claudication without established visual loss: prednisolone 60 mg daily plus same-day ophthalmology.
• •Established or deteriorating visual loss: IV methylprednisolone 500 mg to 1 g daily for 3 days, then prednisolone 60 mg daily; urgent ophthalmology to protect the contralateral eye.
• •Fast-track pathway: urgent ophthalmology and rheumatology review within 24 hours for suspected GCA. Arrange vascular ultrasound and/or temporal artery biopsy alongside treatment.
• •Steroid taper over 12-24 months (often longer): 40-60 mg for 2-4 weeks, then 10 mg reductions every 2 weeks to 20 mg, then 2.5 mg every 2-4 weeks to 10 mg, then 1 mg every 4-8 weeks. Relapses are common.
• •Tocilizumab (NICE TA518) for relapsing or refractory GCA. Reduces relapse and cumulative steroid dose. Important caveat: IL-6 blockade blunts CRP and ESR (and may suppress fever), so relapse monitoring relies on clinical assessment and specialist-led follow-up.
• •Low-dose aspirin (75 mg) is commonly considered to reduce ischaemic complications when not contraindicated.

For both PMR and GCA: assess fracture risk promptly using FRAX and NOGG and start bone protection per NICE NG223 (most patients on 7.5 mg or more prednisolone for over 3 months will qualify); gastroprotection with PPIs; issue an NHS Steroid Emergency Card with sick-day rules; do NOT stop steroids abruptly; monitor blood glucose, blood pressure, weight, mood, and ocular complications (cataract, glaucoma); ensure non-live vaccinations are up to date. Long-term aortic surveillance is recommended in selected GCA patients.

Graded exercise and rehabilitation support both conditions once symptoms are controlled, countering deconditioning and steroid-related morbidity. In PMR, gentle shoulder ROM (pendulums, wall slides) progresses to rotator cuff and deltoid strengthening once steroids reduce pain. Hip, gluteal, quadriceps, and core strengthening protects against falls and is critical in the over-70 age group. Aerobic exercise (walking, cycling, swimming) improves cardiovascular fitness, mood, fatigue, and weight management.

Differentiate steroid myopathy (painless proximal weakness with normal CK and normal inflammatory markers - reduce steroids if disease is quiescent and add progressive strengthening) from PMR relapse (pain plus raised markers - increase steroids). Fatigue management uses pacing, sleep hygiene, and treatment of contributing factors (anaemia, depression, hypothyroidism, steroid effects). PMRGCAuk is a key patient support organisation to signpost.

SEM relevance: masters athletes returning from PMR or GCA need individualised plans that recognise fatigue, fitness loss, steroid-related complications (myopathy, osteoporosis, hyperglycaemia), and cardiovascular risk. At pitchside or event medicine in older event populations, the cardinal warning combination is new headache, jaw claudication, scalp tenderness, or any visual disturbance - these warrant immediate steroid initiation and same-day ophthalmology referral.

• •2012 EULAR/ACR provisional PMR classification criteria - age over 50, bilateral shoulder pain, morning stiffness over 45 minutes, raised CRP/ESR, RF/anti-CCP negativity, and ultrasound findings as a scoring element.
• •2022 ACR/EULAR GCA classification criteria - heavily weight vascular imaging (halo sign, axillary involvement) alongside clinical features.
• •BSR 2020 GCA guidelines - immediate high-dose corticosteroids on clinical suspicion, fast-track pathway with vascular ultrasound and/or temporal artery biopsy, structured steroid taper.
• •NICE TA518 - tocilizumab for relapsing or refractory GCA.
• •NICE CKS PMR and GCA - the UK primary care framework with referral thresholds and the working-diagnosis criteria (70% or more improvement within 1 week, markers normalising within 4 weeks).

• •PMR: bilateral shoulder + pelvic girdle stiffness over 45 minutes, age over 50, raised markers.
• •50% of GCA have PMR; 15% of PMR develop GCA; screen every PMR patient for GCA at each review.
• •GCA: jaw claudication is most specific; AION is preventable with immediate high-dose steroids.
• •Temporal artery biopsy 1 cm or more, within 2 weeks of starting steroids; skip lesions exist.
• •Tocilizumab on board blunts CRP and ESR - monitor clinically (NICE TA518).
• •Fast-track pathway: ophthalmology and rheumatology within 24 hours of suspected GCA.