New Ways to Think about Polymyalgia Rheumatica

As they usually are, the pediatrics are absolutely correct: A child is not just a little adult. The same can be said for the eldest among us: Senior citizens are more than just old adults; they have their own biopsychosocial considerations that we, as rheumatologists, must tend to. Among all the conditions that we find in our clinic, perhaps the most specific to this population is polymyalgia rheumatica. Despite being so common, its predilection for the elderly may be the reason why it has been so overlooked for so long.

Until now. A new generation of intrepid researchers and clinicians is learning more and more about all aspects of polymyalgia rheumatica. Much of the old dogma is being thrown out and replaced with a more nuanced understanding of what it means to carry the diagnosis of polymyalgia rheumatica. In our Polymyalgia Rheumatica in Focus editorial supplement to The Rheumatologist, we review the details of such new thinking.

For so long, the mainstay of polymyalgia rheumatica has been long-term glucocorticoids for presumed disease. The gray areas of the disease remained largely that same shade of gray and nebulous, while other conditions, like rheumatoid arthritis and small-vessel vasculitis were coming to the forefront. Minimized as a self-limited condition that readily responds to immune suppression, patients with severe or relapsing disease were left in the lurch. Worse yet, the subtle, prejudiced undertone that large amounts of glucocorticoids don’t really matter in the long-term for geriatric patients presented barriers to advancement.

Fortunately, newer applications of imaging techniques, such as ultrasound, magnetic resonance imaging and positron emission tomography/computed tomography (PET/CT) are providing greater diagnostic certainly for difficult cases. Drs. Nepal, Sattui and Putman go over the pros and cons of each. And when glucocorticoids and prolonged tapers are unable to induce remission, there are greater opportunities to use IL-6 inhibitors and other immunomodulators. Drs. Spiera, Seo and Sattui provide insights into how to spare steroids and better manage pharmacotherapy. We also examine the complicated relationship between polymyalgia rheumatica and giant cell arteritis, and the patient experience with this condition.

A common theme resonates throughout the supplement: PMR isn’t just aches and pains in the shoulders and hip; it’s a potentially debilitating condition for which we now have an increasing array of options for diagnosis and treatment. Although we don’t advise pediatricians treating PMR, our hope is that this supplement can empower you to restore that sense of youth and vitality in our oldest rheumatology patients.

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the direc tor of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X @BharatKumarMD.