Polymyalgia rheumatica - a common cause of shoulder and hip problems

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Polymyalgia rheumatica (PMR) is an inflammatory arthritis which affects older people, usually over the age of 60, causing stiffness and pain of the muscles and joints round the shoulders and/or hips, worse in the morning but improving as the day progresses. It is diagnosed on the basis of this history and often (but not always) blood tests showing inflammation, ie ESR, creatinine protein or plasma viscosity.

PMR responds reliably well to steroids. In fact I often give patients a trial of steroids to test if that is the diagnosis! With PMR the patient is often much better within 24 hours. Not only is the pain and stiffness gone, but often they feel much better in themselves.

Most people, understandably, throw up their hands in horror at the prospect of taking steroids. However, I have many happy patients who have found immediate relief from their awful arthritis. The next step is to try to find the underlying cause. This is addressed in the page on Arthritis. Sometimes one is lucky and the cause is simply food, such as dairy products. However, increasingly I suspect many cases are due to allergy to gut flora, in which case the management as for the fermenting gut is appropriate. See Fermentation in the gut and CFS. The idea here is that gut microbes are tiny compared to human cells and easily spill over into the bloodstream to cause allergic or pro-inflammatory reactions at distal sites - in this case the shoulders and hips.

The problems of steroids arise when high doses are given for many months. A short course of steroids rarely causes problems. The name of the game is to reduce the dose, not so fast as to cause a relapse, but not so slow as to cause long term side effects. The normal adrenal gland should produce the equivalent of 5 - 7.5 mg of prednisolone daily. With age production levels fall (as the adrenal gland fails) and I suspect this accounts for why PMR becomes more common with age.

The main immediate risk is of a bleed from the gut - this is made much more likely if the patient has been taking aspirin-like pain killers.

What dose of steroid?

I usually start off with at least 30 mg of prednisolone daily. This should improve the symptoms within 24 hours. Indeed, many patients cannot believe the improvement! I tail off the dose of prednisolone to 15 mg daily over one week, then to 10 mg daily over a further 2-3 weeks. However, the initial dose and the rate at which the dose is reduced is a clinical decision. The difficulty is getting down from 10 mg since this is when the joints are most likely to flare. It is much better if the patient is in control since the moment there is a sign of relapse, so the dose can be jacked up again. It may take several weeks to get down to 7 mg, but at this point I am a happy bunny. That is because 7 mg is a physiological dose - that is to say, one is not going to cause long term side effects at this level.

Being on these sorts of doses of steroid is going to turn off one's own production of steroid. Therefore if you try to reduce from 7 mgs quickly I can guarantee the problem will flare. I usually try to reduce at the rate of 1 mg every two weeks, but at the first sign of a flare, jack the dose back up again. The activity of the illness can be monitored by doing tests of inflammation, but really symptoms are the best guide to adjusting the dose of steroid.

Most people can get off the steroids completely after several months. A few are never able to stop completely. I suspect this reflects the fact that the adrenal glands were already failing and this was the reason the PMR set in. Stopping steroids completely merely sets up the very conditions which allowed the PMR to start in the first place.

Once the steroids are stopped, it is well worth checking an adrenal stress profile. The adrenal gland controls levels of inflammation in the body and poor function will result in a tendency to disease accompanied by inflammation. This includes arterial disease.

Also see Inflammation

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