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Polymyalgia Rheumatica

Polymyalgia Rheumatica Syndrome

Polymyalgia rheumatica is an inflammatory disorder that is characterized by pain and stiffness of the neck, shoulders and hips. It may occur before or with giant cell arteritis.


Presentation

Patents with polymyalgia rheumatica generally present with pain and morning stiffness in the shoulder or hip. Patients may have difficulty getting up from a chair, turning over in bed, or raising their arms. Patients are usually in good health prior to the onset of the disease. The presentation is abrupt in 50% of patients [3].

Usually affected joints include those of [2] [3] [4]:

  • Shoulders
  • Hips
  • Knees
  • Metacarpal phalangeal joints
  • Wrists

The shoulders are the most common site, occurring in 70%–95% of patients. Hip and neck pain occurs in 50%–70% of patients [2] [6].

Systemic findings [10]:

The symptoms of polymyalgia rheumatica are often vague and may occur in many other disorders [3] [4] [6].

Diagnostic criteria for polymyalgia rheumatica are [10] [11]:

  • Age 50 years or older
  • Erythrocyte sedimentation rate ≥40 mm/h
  • Pain lasting longer than 1 month and involving at least 2 sites 
  • Exclusion of other diseases with similar symptoms 
  • Morning stiffness lasting more than 1 hour
  • Rapid response to corticosteroids

Some patients exhibit a chronic-relapsing course and may need low doses of corticosteroids for many years [4].

Pain
  • Adjusted linear regression analysis demonstrated that high (NRS 8) pain (0.20 (95% CI 0.10-0.28)) or stiffness (0.18 (0.09-0.26)) ratings, an increasing number of sites of pain (0.18 (0.06-0.29)) or stiffness (0.19 (0.08-0.31)) and shoulder pain (0.18[ncbi.nlm.nih.gov]
  • […] tests can help narrow down the cause of the pain.[en.wikipedia.org]
  • Hip and neck pain occurs in 50%–70% of patients.[symptoma.com]
  • A syndrome in the elderly characterized by proximal joint and muscle pain, high erythrocyte sedimentation rate, and a self-limiting course. Pain is usually accompanied by evidence of an inflammatory reaction.[icd9data.com]
Fever
  • Other symptoms include fever, weakness and weight loss. In some cases, polymyalgia rheumatica develops overnight. In others, it is gradual.[icd9data.com]
  • In addition to stiffness, you may have a fever, weakness, and weight loss. Polymyalgia rheumatica usually goes away within one year, but it could last several years.[niams.nih.gov]
  • A 56-year-old African American woman who was on triple immunosuppressive therapy (which includes tacrolimus, mycophenolate mofetil, and prednisone) for a renal transplant that she had received 10 years ago presented with malaise, low-grade fevers and[ncbi.nlm.nih.gov]
Weight Loss
  • In addition to stiffness, you may have a fever, weakness, and weight loss. Polymyalgia rheumatica usually goes away within one year, but it could last several years.[niams.nih.gov]
  • Associated symptoms include low-grade fever, malaise, fatigue, low mood, poor appetite, and weight loss. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR.[ncbi.nlm.nih.gov]
  • Other symptoms include fever, weakness and weight loss. In some cases, polymyalgia rheumatica develops overnight. In others, it is gradual.[icd9data.com]
Fatigue
  • Associated symptoms include low-grade fever, malaise, fatigue, low mood, poor appetite, and weight loss. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR.[ncbi.nlm.nih.gov]
  • Scalp tenderness, fatigue, fevers and a general sense of illness occurs in about 50% of patients. Jaw or facial soreness, especially with chewing, also occurs in about 50% of patients.[my.clevelandclinic.org]
Malaise
  • A 56-year-old African American woman who was on triple immunosuppressive therapy (which includes tacrolimus, mycophenolate mofetil, and prednisone) for a renal transplant that she had received 10 years ago presented with malaise, low-grade fevers and[ncbi.nlm.nih.gov]
  • […] most prominent in the morning and after rest; systemic Sx are vague–aching of 30 mins, affecting 2 major joints, in descending order, shoulder, hips and thighs, or neck/torso Pt profile age 70; : , 2:1 Clinical Pain exacerbated by movement, fatigue, malaise[medical-dictionary.thefreedictionary.com]
  • Systemic findings: Low-grade fever Weight loss Malaise Fatigue Difficulty completing activities of daily living The symptoms of polymyalgia rheumatica are often vague and may occur in many other disorders.[symptoma.com]
Loss of Appetite
  • BACKGROUND: A 73-year-old, previously well woman was admitted to an emergency department because of a 3-month history of severe proximal girdle pain and stiffness with loss of appetite and weight.[ncbi.nlm.nih.gov]
  • Some people with polymyalgia rheumatica have additional symptoms, including: feeling very tired loss of appetite weight loss depression When to get medical advice See your GP if you have symptoms of pain and stiffness that last longer than a week.[nhs.uk]
  • Possible Symptoms of PMR Impaired Range of mMotion Low fever Pain in shoulders (often first symptom), neck, hip or thigh Fatigue (tiredness, weakness, low energy) Loss of appetite Unintended weight loss Possible Intervention Physical therapy Healthy diet[geriatricpain.org]
Malocclusion
  • She presented clinically with a skeletal Class II malocclusion with severe overbite and overjet. All her remaining dentition was determined to be unrestorable.[ncbi.nlm.nih.gov]
Night Sweats
  • Other clues are fatigue, weight loss, a slight temperature, night sweats and feeling unwell. Giant cell arteritis (GCA) is a rare condition linked to PMR, caused by inflammation of medium and large arteries, usually in the head and neck.[saga.co.uk]
  • Associated constitutional symptoms often include anorexia, fatigue, weight loss, low-grade fevers, and occasional night sweats. Synovial swelling is seen in 20% to 35% and may occur in the wrists, knees, and small joints of the hands.[rheumaknowledgy.com]
Arthritis
  • Report of a Ten‐Year Study in Shelby County, Tennessee, Arthritis & Rheumatism, 26, 10, (1214-1219), (2005). D. Pongratz and W.[doi.org]
  • We report here cases of rheumatoid arthritis (RA) and polymyalgia rheumatica (PMR) occurring after ICI treatment.[ncbi.nlm.nih.gov]
Myalgia
  • The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss.[ncbi.nlm.nih.gov]
  • It is important to note that although “myalgia” means muscle pain, the muscles are usually spared and it’s the tissue around the joints that mostly gets inflamed.[osmosis.org]
Muscle Weakness
  • There is no true muscle weakness nor evidence of muscle disease on electromyography (EMG) or on biopsy.[healthcentral.com]
  • Snapshot A 60-year-old woman presents to her physician's office for headache and muscle weakness. She reports that she usually never has headaches but recently started experiencing headaches in the morning about 2 weeks ago.[step2.medbullets.com]
  • Although there was no evidence of proximal muscle weakness, EMG was done which was reported as normal.[omjournal.org]
  • Sometimes, pain and stiffness can lead to lack of use of some body parts, which could result in muscle weakness. Most people with PMR have pain and stiffness in at least two of the following areas: Buttocks. Hips. Neck. Thighs.[arthritis.org]
Shoulder Pain
  • Adjusted linear regression analysis demonstrated that high (NRS 8) pain (0.20 (95% CI 0.10-0.28)) or stiffness (0.18 (0.09-0.26)) ratings, an increasing number of sites of pain (0.18 (0.06-0.29)) or stiffness (0.19 (0.08-0.31)) and shoulder pain (0.18[ncbi.nlm.nih.gov]
  • After stabilization for bleeding he was evaluated for shoulder pain. He reported increasing pain and stiffness in his shoulder and pelvic girdle over 1 month.[jrheum.org]
  • The diagnosis of PMR is based on clinical features such as new-onset bilateral shoulder pain, including subdeltoid bursitis, muscle or joint stiffness, and functional impairment.[jamanetwork.com]
Myopathy
  • METHODS: We studied 60 patients who had undergone 18 F-FDG PET/CT scans for workup of suspected PMR, arthritis, enthesitis, or myopathy. Final diagnoses were made by board-certified rheumatologists.[ncbi.nlm.nih.gov]
  • On the other hand, patients with statin-associated myopathy may have normal serum CK levels which make it sometimes difficult to distinguish PMR from myopathic syndromes [33] .[journals.plos.org]
  • Polymyalgia rheumatica is differentiated from inflammatory myopathy ( DM and PM ) by the absence of frank muscle weakness or characteristic skin and other nonmusculoskeletal findings.[rheumaknowledgy.com]
  • Inflammatory myopathies (dermatomyositis, polymyositis ) Non-inflammatory musculoskeletal disorders such as Rotator-cuff diseases (rotator cuff tears, rotator cuff tendinopathy) Adhesive capsulitis Degenerative joint disease (degeneratieve disc disease[physio-pedia.com]
Headache
  • The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss.[ncbi.nlm.nih.gov]
  • Snapshot A 60-year-old woman presents to her physician's office for headache and muscle weakness. She reports that she usually never has headaches but recently started experiencing headaches in the morning about 2 weeks ago.[step2.medbullets.com]
Asthenia
  • However, at that time, she started to complain of asthenia, abdominal cramping and pain on the left side, weight loss and bloody diarrhoea. A colonoscopy confirmed a diagnosis of left-sided UC.[ncbi.nlm.nih.gov]
  • Muscle tenderness, peripheral synovitis, arthritis, carpal tunnel syndrome or distal tenosynovitis, as well as non-specific symptoms, such as fatigue, asthenia, malaise, low-grade fever, anorexia and weight loss, may be associated.[orpha.net]

Workup

There is no definitive diagnostic test for polymyalgia rheumatica [3]. A rapid response to corticosteroids is considered diagnostic. Lack of response may indicate an incorrect diagnosis [9] [10].

Laboratory studies [12]

  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Complete blood count (CBC) with differential
  • Liver function tests
  • Creatine kinase level
  • Serum creatinine and urinalysis
  • Thyroid function test
  • Serum calcium
  • Blood glucose

White blood cell count in polymyalgia rheumatica is normal or mildly elevated. Platelet count is increased indicating systemic inflammation [3] [12].

Erythrocyte sedimentation rate (ESR) is the test most sensitive for polymyalgia rheumatica, but is not specific. It may be elevated in any inflammatory disease and may not always be elevated in polymyalgia rheumatica [3] [4] [10].

Serum interleukin 6 (IL-6) levels are elevated and rise and fall with disease activity. This test is not readily available in all laboratories [10].

Antinuclear antibodies, rheumatoid factor, and anticyclic citrullinated peptide (anti-CCP) levels are usually normal [10].

Other procedures

Synovial fluid aspiration in patients with synovitis show signs of inflammation, white blood cell counts of 1,300-11,000 cells/µL, with 34% polymorphonuclear leukocytes [12].

Radiographic studies show normal joints or mild osteoarthritis. More extensive arthritis indicates other disorders such as rheumatoid arthritis.

Magnetic resonance imaging (MRI) is not necessary for diagnosis, but reveals bursitis and synovitis [12] [13].

Ultrasonography may be helpful for differential diagnosis. In polymyalgia rheumatica shoulder, bursa effusions may be seen [13].

There are no reliable tests for predicting the possible recurrence in polymyalgia rheumatica. Erythrocyte sedimentation rate (ESR) has been used for this, but results are inconsistent [9]. C-reactive protein and interleukin-6 may be more sensitive predictors [9].

Thrombocytosis
  • Most people with polymyalgia rheumatica have an unusually high number of these cells (thrombocytosis). On the other hand, many people with polymyalgia rheumatica have a lower number of red blood cells than normal and are often anemic.[web.archive.org]
  • Anemia of chronic disease, leukocytosis, reactive thrombocytosis, and decreased albumin are also common. Alkaline phosphatase and hepatic enzymes may be elevated.[rheumaknowledgy.com]
  • Such abnormalities can include a mild normocytic anemia due to chronic inflammation, leukocytosis, and thrombocytosis. Inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) frequently are elevated.[practicalpainmanagement.com]
  • Hayreh 2003 points out that although essential thrombocytosis has increased thrombotic morbidity, the thrombocytosis in GCA is reactive and thus an antithrombotic agent is likely to have little effect.[doi.org]
Elevated Sedimentation Rate
  • New York: McGraw-Hill, 1997. pol·y·my·al·gi·a rheu·ma·ti·ca a syndrome within the group of collagen diseases different from spondylarthritis or from humeral scapular periarthritis by the presence of an elevated sedimentation rate; much commoner in women[medical-dictionary.thefreedictionary.com]
  • Diagnosis The diagnosis of polymyalgia rheumatica may be confirmed by a thorough clinical examination including a detailed patient history and specialized blood testing that demonstrates an abnormally elevated sedimentation rate.[rarediseases.org]
  • Elevated sedimentation rate and elevated acute phase reactions are hallmarks of this disease. It is primarily a disorder of elderly Caucasians of northern European ancestry.[reliasmedia.com]

Treatment

The diagnosis of polymyalgia rheumatica is often made after an extensive workup to exclude other diseases. This delays treatment and relief of symptoms [6].

The goal of treatment is to control pain, reduce stiffness, prevent systemic components, and prevent the effect of the disease on daily life [6] [11].

Corticosteroids are the treatment of choice, as they result in complete or near-complete symptom relief and normalization of erythrocyte sedimentation rate [3] [4]. Starting doses of prednisone of 10 to 15 mg/day are recommended [6]. Expect relief of symptoms within 24-72 hours. If symptoms are not well controlled within 1 week, steroid doses should be increased until they are [6] [14]. Once symptoms are controlled and erythrocyte sedimentation rates have dropped, slow tapering by 1 mg/month is recommended [14].

Inflammatory markers document the progression of the disease, but should not be used to decrease or stop treatment. Patient-reported complaints of pain, morning stiffness, and physical and mental function are the best measures of disease activity and response to treatment [3] [4] [6] [14].

Long-term high cumulative doses of corticosteroids have been associated with more adverse effects [6] [14]. If not contraindicated, non-steroidal anti-inflammatory medications may be used for supplemental pain relief [6] [14].

Corticosteroid-sparing agents in patients with polymyalgia rheumatica may reduce corticosteroid adverse effects. It is of particular benefit in diabetic patients or those with osteonecrosis [3] [5].

  • Methotrexate at 7.5 mg/week along with prednisone showed decreased complications [15]. 
  • Tumor necrosis factor alpha (TNF-α), Etanercept, reduces the cumulative dose of prednisone needed [15]. Results have been variable, but indicate the drug to be safe [10].

Relapses are common in polymyalgia rheumatica. Close, frequent follow-up is necessary to monitor for relapse and long-term complications of corticosteroid use. Medications for treatment of osteoporosis and gastrointestinal ulcer prophylaxis should be instituted as necessary [3] [4].

Diet

Calcium and vitamin D supplements should be prescribed for all patients with polymyalgia rheumatica on starting corticosteroid therapy [3] [4].

Activity

No activity restriction are recommended. Physical therapy for those with difficulty with mobility and activities of daily living may be needed.

Follow-up

Patients on corticosteroids should be followed monthly to track disease progress. After tapering of the steroid dosage, quarterly follow-up should be sufficient to identify possible relapses [5] [15].

Relapses occur in approximately 50% of patients, most often within 1 year of corticosteroid withdrawal. All patients should be monitored for symptom of recurrence during tapering of corticosteroids and for 12 months after therapy [5]. If symptoms recur prednisone is still the drug of choice [5].

Prognosis

Polymyalgia rheumatica is a chronic, recurring disorder. It may last as long as 2 years or more. Recurrences occur in 40-50% of patients [8]. Prognosis is generally good.

Adverse complications of corticosteroid use, osteoporotic fractures and diabetes mellitus, are common. One study reported 65% of patients had at least one serious corticosteroid complication [9].

Polymyalgia rheumatica has been associated with atherosclerosis and a higher risk of cardiovascular and cerebrovascular disease [2]. The use of corticosteroids may actually decrease this risk by controlling inflammation [2].

Quality of life, both physical and mental, may be affected by polymyalgia rheumatica. Pain and morning stiffness may reduce physical quality of life, while disability and decreased function may cause depression [7].

Etiology

The symptoms of polymyalgia rheumatica are due to inflammation [3]. The exact cause of the inflammation is unknown. An autoimmune process may be involved in polymyalgia rheumatica because it is associated with a high level of Interleukin 6 (IL-6) [5].

Epidemiology

The mean incidence of polymyalgia rheumatica is 52.5 cases per 100,000 persons 50 years and older, with a prevalence of 0.5-0.7% [4].

Polymyalgia rheumatica occurs most frequently in Caucasians, only occasionally occurring in Africans and Hispanics [4] [5] [6].
Polymyalgia rheumatica develops almost always in individuals over the age of 50 with the mean age of 72 years. The incidence of polymyalgia rheumatica increases with age [6] [7].

Women are affected two to three times more often than men [5] [6].

Sex distribution
Age distribution

Pathophysiology

The exact cause is not known. Polymyalgia rheumatica presents as inflammation of the shoulders, hips, knees, and wrists. Inflammation is thought to start in response to an unknown antigen [3]. This disease is often associated with significantly elevated indicators of inflammation such as erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) [6]. Rapid response to corticosteroids is the only consistent diagnostic finding [6]. The lack of response to corticosteroids indicates the need to question the diagnosis [3].

A genetic component predisposing some individuals to the disorder is suspected because of the higher incidence among Northern Europeans and in family members [3] [5]. This hypothesis postulates that in genetically predisposed patients an environmental factor, possibly a virus, causes white blood cell activation with the production of cytokines [2].

An autoimmune process may also occur in polymyalgia rheumatica. Patients usually have an elevated Interleukin 6 level which is likely responsible for the systemic inflammatory response [2] [3] [5].

Polymyalgia rheumatica may be associated with the aging process as it occurs almost entirely in those over 50 years of age and the incidence increases with age.

Prevention

Polymyalgia rheumatica cannot be prevented at this time. The pain, disability, and the effects on quality of life can be prevented with early diagnosis and prompt treatment.

The use of steroid-sparing agents, such as methotrexate may reduces the serious corticosteroid-related complications [9]. The prevention of and early treatment of osteoporosis and uncontrolled diabetes will potentially prevent the many, serious complications of these disorders.

Summary

Polymyalgia rheumatica is a common disorder of the elderly, individuals 50+ years [1] [2]. It is a chronic inflammatory disease of unknown etiology characterized by pain in the hip and shoulder girdles with morning stiffness that lasts for more than 1 hour [2].

Polymyalgia rheumatica affects the proximal muscles and joints, and may cause disability in older adults [3] [4]. It is diagnosed by the presenting symptoms and the exclusion of other diagnoses. A rapid response to corticosteroids, the treatment of choice, is considered diagnostic [1].

Polymyalgia rheumatica has an excellent prognosis [5]. However, recurrences are common [1] [2]. More than 50% of patients remain on steroids for 2 years or more [2].

Although the etiology of polymyalgia rheumatica is unknown, infectious or environmental agents may be triggers [6]. A genetic component is also suspected, as the disorder occurs more often in individuals of Northern European descent and in family members.

Polymyalgia rheumatica is often a co-morbid disorder with giant cell arteritis. Approximately 15% of patients with polymyalgia rheumatica develop giant cell arteritis and 40-50% of patients with giant cell arteritis have a history of polymyalgia rheumatica [1] [2].

Patient Information

What is polymyalgia rheumatica?

Polymyalgia rheumatica is a relatively common inflammatory disease of older adults. Peak incidence is after 50 years of age. It causes pain and morning stiffness of the shoulders, hips, neck, and wrists. It is a self-limited condition which resolves in months to several years with no residual effects. However, relapses occur in 40 to 50 % of patients.

What are the symptoms of polymyalgia rheumatica?

Symptoms of polymyalgia rheumatica include:

  • Pain in the joints of the shoulders, hips, neck, and wrists
  • Morning stiffness lasting longer than 1 hour
  • Difficulty preforming activities of daily living
  • Low-grade fever
  • Weight loss
  • Malaise
  • Fatigue

What causes polymyalgia rheumatica?

The cause of polymyalgia rheumatica is unknown. There are several theories related to its occurrence. It is felt that polymyalgia rheumatica may be an autoimmune (the body’s immune system attacking itself) inflammatory disease triggered by an infection or environmental agent. Another theory purposes a genetic factor that predisposes certain individuals to acquiring the disease.

Who gets polymyalgia rheumatica?

Polymyalgia rheumatica occurs almost exclusively in individuals older than 50 years of age with a mean age of 72 years.
Polymyalgia rheumatica is twice as common in females as males.
It is primarily a disease of Caucasians, only occurring rarely in African Americans and Hispanics. The incidence of polymyalgia rheumatica is highest in those of Northern European descent.

How is polymyalgia rheumatica diagnosed?

There is no specific test for polymyalgia rheumatica. It is usually diagnosed by its presenting symptoms and the fact that they respond quickly to corticosteroid medications. Some blood tests that indicate inflammation will also be used to diagnose the disease and response to treatment.

How is polymyalgia rheumatica treated?

Polymyalgia rheumatica is treated almost exclusively with corticosteroids like prednisone. Other medications may be added to reduce the dose of prednisone needed.

What are the complications of polymyalgia rheumatica?

The complications of polymyalgia rheumatica include short-term disability associated with pain and stiffness and decreased quality of life.
Other complications are not a result of the disease itself, but to long-term corticosteroids use. These complications include severe osteoporosis and uncontrolled diabetes mellitus.

References

Article

  1. Gonzalez-Gay MA, Barros S, Lopez-Diaz MJ, Garcia-Porrua C, Sanchez-Andrade A, Llorca J. Giant cell arteritis: disease patterns of clinical presentation in a series of 240 patients. Medicine. 2005;84(5):269-76.
  2. Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, et al. Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009;61(10):1454-61.
  3. Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013;88(10):676-84.
  4. Gonzalez-Gay MA, Garcia-Porrua C, Miranda-Filloy JA, Martin J. Giant cell arteritis and polymyalgia rheumatica: pathophysiology and management. Drugs Aging. 2006;23(8):627-49.
  5. Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum. 1984;13(4):322-8.
  6. Hernández-Rodríguez J, Cid MC, López-Soto A, Espigol-Frigolé G, Bosch X. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med. 2009;169(20):1839- 45.
  7. González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, Dababneh A, Hajeer A, Ollier WE. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol. 1999;26(6):1326-32.
  8. Salvarani C, Cantini F, Niccoli L, Macchioni P, Consonni D, Bajocchi G, et al. Acute-Phase Reactants and the Risk of Relapse/Recurrence in Polymyalgia Rheumatica: A Prospective Followup Study. Arthritis & Rheumatism. 2005, 53, (1); 33–38.
  9. Hancock AT, Mallen CD, Belcher J, Hider SL. Association Between Polymyalgia Rheumatica and Vascular Disease: A Systematic Review. Arthritis Care & Research, 2012, 64(9), 1301–1305.
  10. Hutchings A, Hollywood J, Lamping DL, Pease CT, Chakravarty K, Silverman B, Choy DG, et al. Clinical Outcomes, Quality of Life, and Diagnostic Uncertainty in the First Year of Polymyalgia Rheumatica. Arthritis & Rheumatism. 2007, 57(5), 803–809.
  11. Catanoso MG, Macchioni P, Boiardi L, Pipitone N, Salvarani C. Treatment of Refractory Polymyalgia Rheumatica With Etanercept: An Open Pilot Study. Arthritis & Rheumatism, 2007;57(8), 1514–1519.
  12. Dasgupta B, Cimmino MA, Kremers HM, Schmidt WA, Schirmer M, Salvarani C, et al. Provisional Classification Criteria for Polymyalgia Rheumatica. Arthritis & Rheumatism, 2012; 64(4), 943–954.
  13. Kennedy S. Polymyalgia rheumatica and giant cell arteritis: An in-depth look at diagnosis and treatment. Journal of the American Academy of Nurse Practitioners. 2012;24: 277–285.
  14. Leeb B, Bird H, Nesher G, Ande I , Hueber W, Logar D, Montecucco C, et al. EULAR response criteria for polymyalgia rheumatica: results of an initiative of the European Collaborating Polymyalgia Rheumatica Group. Ann Rheum Dis. 2003; 62(12): 1189–1194. 
  15. Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013; 88(10):676-84.

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Last updated: 2019-07-11 20:53