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Polymyalgia rheumatica - Management
How should I manage relapses in someone with polymyalgia rheumatica?

  • If the person develops symptoms or signs suggestive of giant cell arteritis, see the CKS topic on Giant cell arteritis.
    • Features of giant cell arteritis include headache; scalp tenderness; jaw claudication; tender, thickened temporal arteries; and visual symptoms such as diplopia and visual loss.
    • Visual symptoms need urgent (same day) referral to an ophthalmologist.
  • If the person has features that suggest a relapse of polymyalgia rheumatica alone (such as shoulder or pelvic girdle pain and stiffness):
    • Increase prednisolone to the previous higher dose and monitor for response.
      • ▪If symptoms settle, it may be wise to continue on the higher dose for longer than usual before following the suggested tapering schedule — see Ongoing management.
      • ▪If symptoms do not improve, increase the dose of prednisolone further and seek specialist advice.
  • If the person has frequent relapses, or it is not possible to taper steroids, specialist input is strongly recommended so that the diagnosis can be reviewed and adjuvant therapy considered.
    • A relapse should be evaluated with regard to symptoms and signs, as well as assessment for related conditions (especially giant cell arteritis), and not solely on the basis of raised inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) [Dasgupta et al, 2007].
      • If ESR or CRP are persistently elevated, consider other causes for the symptoms (for example malignancy, multiple myeloma, infection, or connective tissue disease).
      • The dose of prednisolone should not be increased to try to reduce a persistently high ESR or CRP [Michet and Matteson, 2008].

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