Polymyalgia Rhumatica Treatment

Early Treatment of PMR

                    
Polymyalgia Rheumatica treatment usually starts with the steroid prednisolone (prednisone in the USA). It is part of a group of drugs called glucocorticosteroids, which imitate the 'natural' cortisone that our body manufactures in order to regulate bodily functions, including the immune system.
 
Once steroid treatment begins, immediate relief can be spectacular. However, after a welcome break, it’s usually not long before the symptoms start to reappear.
 
When I started taking the steroids, within hours I went from hobbling with a walking stick to running up the stairs. It felt like a miracle. People who have not experienced PMR might find it difficult to understand what ‘muscle pain all over the place’ really is like. For me the stiffness was of a completely different order than I had ever experienced before, including the stiffness after running the London marathon.The pain went beyond any pain I had ever experienced in my muscles or joints. With this level of pain it is impossible to concentrate, to work, to get on with daily life. The steroids give us our lives back, but at a cost. There are side effects, and it is not ideal to remain on a high dose for long. We’ll look at this further later.
 
Prednisolone works because it deals with the symptoms and restores something approaching normal life to the patient. It is an unusually cheap drug as well, which is fortunate for our public National Health System. For someone who starts on 15mg per day and continues with a typical course of the drug over two years, the cost to the NHS is approximately £30. It is no wonder that prednisolone is the drug of choice for PMR. It does the job. It removes the worst of the pain. It restores quality of life, keeps people out of the doctor’s surgery, and it’s as cheap as chips.
 
 

Long Term Polymyalgia Rheumatica Treatment


The British Society of Rheumatologists guidelines for the treatment of PMR suggest starting the patient off on 15mg of prednisolone per day, with a progressive tapering down to a ‘maintenance dose’ of 5-7mg  once symptoms have been stabilized. Once this is achieved your doctor will want to taper down further, until you no longer suffer from symptoms, and are no longer taking steroids. This typically takes at least a couple of years, with the average recovery time being approximately three and a half years. My recovery took around four years.
 
The quality of long term Polymyalgia Rheumatica treatment varies significantly in different areas. Good quality care should take into account the effect of the illness on the patient holistically, looking at how badly it affects all areas of their life. Often treatment is restricted to the prescription and management of steroids, without considering the patient’s situation overall.
 
After listening to many patients’ stories, my gut feeling is that many (not all) doctors regard PMR as an old woman's Illness. Elderly women in western society are generally discounted, joked about, and rendered invisible in public life. They may not be the priority in the provision of pro-active effective healthcare. And of course, 25% of PMR patients are men anyway.
 
In my opinion PMR patients should be assessed not only on their physical condition, but also consulted with about social and circumstantial factors such as the following, in order to provide to quality care:
 
  • Is this patient a man or a woman? Bearing in mind that often men will be averse to admitting they are having a difficult time of it.
 
  • Is this person in employment? What is the nature of their employment and how sympathetic and supportive is their employer likely to be?
 
  • Is this person in their 50s (or even late 40s)? In my view every case under 55 should be referred to a specialist rather than being treated solely in primary care.
 
  • Is this person a carer? If they were unable to continue caring because of PMR/GCA, what would the consequences be for the family?
 
  • What is their current level of physical activity? How can they be helped to continue their physical activity, maybe at a reduced level? Would physiotherapy be of any help? (should routinely be asked at various stages in the course of the illness)
 
  • Does this person already have weight/obesity issues? How can this person best be helped to maintain and if possible improve their nutrition while they have PMR?
 
  • How proactive is this person likely to be in managing their condition themselves? How can they best be encouraged to access sources of information and support that will be able to help them? Who else in their lives needs to know about and understand PMR?
Is this patient a man or a woman? Bearing in mind that often men will be averse to admitting they are having a difficult time of it.
 
Is this person in employment? What is the nature of their employment and how sympathetic and supportive is their employer likely to be?
 
Is this person in their 50s (or even late 40s)? In my view every case under 55 should be referred to a specialist rather than being treated solely in primary care.
Is this person a carer? If they were unable to continue caring because of PMR/GCA, what would the consequences be for the family?
 
What is their current level of physical activity? How can they be helped to continue their physical activity, maybe at a reduced level? Would physiotherapy be of any help? (should routinely be asked at various stages in the course of the illness)
 
Does this person already have weight/obesity issues? How can this person best be helped to maintain and if possible improve their nutrition while they have PMR?
 
How proactive is this person likely to be in managing their condition themselves? How can they best be encouraged to access sources of information and support that will be able to help them? Who else in their lives needs to know about and understand PMR?
 
PMR is generally not life threatening and people who start well have a fair prospect of recovery, but it is a serious illness and potentially grave because of the collateral damage it can do. I am not suggesting that doctors should take all the burden of this on themselves, but at least have the conversation that treats the patient holistically and as an individual. Also informing all patients of the risk and cardinal symptoms of Giant Cell Arteritis is paramount. It is amazing how many PMR patients have no idea. It is as though, having finally got a diagnosis, the GP breathes a sigh of relief, writes the script, and shows the patient the door.