NEJM Clinical Practice Review: Polymyalgia Rheumatica Diagnosis and Management in Adults Over 50

Polymyalgia rheumatica (PMR) is an inflammatory condition affecting persons older than 50 years of age, characterized by bilateral shoulder pain with or without hip or neck pain and pronounced morning stiffness lasting more than 45 minutes. It is one of the most common inflammatory rheumatic diseases in older adults, with incidence peaking in persons over 70 and a notable female predominance. PMR may occur concurrently with giant cell arteritis in up to 15 to 20% of cases, and evaluating for this overlap is an important part of the diagnostic workup.

Diagnosis rests primarily on clinical features and laboratory evidence of systemic inflammation, particularly elevated erythrocyte sedimentation rate and C-reactive protein, in the absence of an alternative explanation. Imaging with ultrasound or MRI can support the diagnosis by demonstrating subdeltoid and trochanteric bursitis, but is not required. Standardized classification criteria, such as the 2012 ACR/EULAR provisional criteria, are useful as a framework but are intended to support rather than replace clinical judgment.

Glucocorticoids remain the mainstay of treatment, with an initial dose of 12.5 to 25 mg of prednisone equivalent daily producing rapid and dramatic symptom relief, which itself has diagnostic value. The review outlines a structured approach to steroid tapering, ideally completed within 12 months, though longer courses are required in many patients. Relapses are common, occurring in 40 to 60% of patients, and in these cases the addition of interleukin-6 receptor inhibitors such as sarilumab or tocilizumab, or the use of methotrexate, can reduce cumulative glucocorticoid exposure and facilitate successful tapering. Monitoring for glucocorticoid-related complications, including osteoporosis, hyperglycemia, and adrenal insufficiency, is emphasized as an integral component of long-term management.