Polymyalgia rheumatica (PMR)

What to look for

• Age 50 or older with bilateral shoulder and/or hip girdle pain, morning stiffness over 45 minutes
• Raised ESR or CRP, normal CK
• Usually a rapid, marked response to moderate-dose glucocorticoids, though response alone does not confirm the diagnosis
• Atypical: age under 60, peripheral arthritis, normal markers, poor steroid response, or prominent systemic symptoms

What to do

• Check for GCA features (headache, scalp tenderness, jaw claudication, visual symptoms, limb claudication). If present, treat as emergent.
• Without GCA features, PMR is semi-urgent. It can often be managed in primary care. If you're not comfortable with the diagnosis or treatment, refer: it's better for the patient to be seen sooner rather than later.
• Send ESR, CRP, CBC, metabolic panel, CK, TSH, RF/anti-CCP, and serum protein electrophoresis to look for mimics such as RA, myeloma and other cancers, myopathy and hypothyroidism. Complete the workup before glucocorticoids start; a 'trial of steroids' shouldn't be used as a diagnostic test (EULAR 2025).
• Guidelines differ on referral: EULAR 2025 recommends rapid specialist referral of all suspected PMR, while BSR 2026 expects most PMR to be managed in primary care with specialist support, referring atypical features, a second relapse, or 18 months or more of glucocorticoids. Follow your local pathway.
• Treatment: prednisone 15–25 mg daily, tapered to 10 mg daily within about 2 months, then slowly. Plan bone protection.
• Refer, or ask for advice, for atypical features, relapse on taper, or inability to taper. Sarilumab, tocilizumab and methotrexate are steroid-sparing options.

About this urgency level

Specialist evaluation helps, but these are usually less time-sensitive than new inflammatory arthritis or connective tissue disease.

Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.