Polymyalgia Rheumatica: The Daily PANCE Blueprint
A 72-year-old woman has six weeks of aching and stiffness in both shoulders and hips. She struggles to lift her arms to comb her hair and to rise from a low chair, and the stiffness lasts more than an hour every morning. She has lost 4 pounds and feels generally unwell. On examination her muscle strength is normal despite the difficulty, and there is no joint swelling. ESR is 78 mm/hr and C-reactive protein is elevated; creatine kinase and rheumatoid factor are normal. She denies headache, scalp tenderness, and visual symptoms. Which of the following is the most appropriate treatment?
A. High-dose prednisone at 1 mg/kg daily
B. Methotrexate weekly
C. Ibuprofen scheduled three times daily
D. Physical therapy alone
E. Low-dose prednisone at 15 mg daily
Answer and topic summary
The answer is E. Low-dose prednisone at 15 mg daily
Bilateral shoulder and hip girdle pain with prolonged morning stiffness, a markedly elevated ESR, and normal strength and creatine kinase in a patient over 50 is polymyalgia rheumatica. That combination of normal strength with a normal CK is what separates it from an inflammatory myopathy like polymyositis, where genuine weakness and a high CK dominate. Treatment is low-dose prednisone, typically 12.5 to 25 mg daily, and the response is so brisk and dramatic — often within 24 to 72 hours — that a poor response should make you question the diagnosis. The trap is reaching for high-dose prednisone at 1 mg/kg, which is the regimen for giant cell arteritis, not for PMR. That distinction matters enormously: roughly 15% of PMR patients develop GCA, so you must screen at every visit for new headache, scalp tenderness, jaw claudication, and visual change — she has none — and if any appear, start high-dose steroids immediately and biopsy the temporal artery, because vision loss is irreversible. Methotrexate is a steroid-sparing add-on, not first-line, and NSAIDs alone are inadequate.
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