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Polymyalgia Rheumatica and Giant Cell Arteritis
Questions and Answers about Polymyalgia Rheumatica and Giant Cell Arteritis
This publication contains general information about polymyalgia rheumatica and giant cell arteritis. It describes what they are, their causes, and treatment options. Highlights of research are also included. If you have further questions, you may wish to discuss them with your health care provider.
Polymyalgia rheumatica is a rheumatic disorder associated with moderate-to-severe musculoskeletal pain and stiffness in the neck, shoulder, and hip area. Stiffness is most noticeable in the morning or after a period of inactivity. This disorder may develop rapidly; in some people it comes on literally overnight. But for most people, polymyalgia rheumatica develops more gradually.
The cause of polymyalgia rheumatica is not known. But it is associated with immune system problems, genetic factors, and an event, such as an infection, that triggers symptoms. The fact that polymyalgia rheumatica is rare in people under the age of 50 and becomes more common as age increases, suggests that it may be linked to the aging process.
Polymyalgia rheumatica usually resolves within 1 to several years. The symptoms of polymyalgia rheumatica are quickly controlled by treatment with corticosteroids, but symptoms return if treatment is stopped too early. Corticosteroid treatment does not appear to influence the length of the disease.
Giant cell arteritis is a form of vasculitis, a group of disorders that results in inflammation of blood vessels. This inflammation causes the arteries to narrow, impeding adequate blood flow. In giant cell arteritis, the vessels most involved are those of the head, especially the temporal arteries (located on each side of the head). For this reason, the disorder is sometimes called temporal arteritis. However, other blood vessels can also become inflamed in giant cell arteritis. For a good prognosis, it is critical to receive early treatment, before irreversible tissue damage occurs.
It is unclear how or why polymyalgia rheumatica and giant cell arteritis frequently occur together. But some people with polymyalgia rheumatica also develop giant cell arteritis either simultaneously, or after the musculoskeletal symptoms have disappeared. Other people with giant cell arteritis also have polymyalgia rheumatica at some time while the arteries are inflamed.
When undiagnosed or untreated, giant cell arteritis can cause potentially serious problems, including permanent vision loss and stroke. So regardless of why giant cell arteritis might occur along with polymyalgia rheumatica, it is important that doctors look for symptoms of the arteritis in anyone diagnosed with polymyalgia rheumatica.
Patients, too, must learn and watch for symptoms of giant cell arteritis, because early detection and proper treatment are key to preventing complications. Any symptoms should be reported to your doctor immediately.
In addition to the musculoskeletal stiffness mentioned earlier, people with polymyalgia rheumatica also may have flu-like symptoms, including fever, weakness, and weight loss.
Early symptoms of giant cell arteritis may resemble flu symptoms such as fatigue, loss of appetite, and fever. Symptoms specifically related to the inflamed arteries of the head include headaches, pain and tenderness over the temples, double vision or visual loss, dizziness or problems with coordination, and balance. Pain may also affect the jaw and tongue, especially when eating, and opening the mouth wide may become difficult. In rare cases, giant cell arteritis causes ulceration of the scalp.
Caucasian women over the age of 50 have the highest risk of developing polymyalgia rheumatica and giant cell arteritis. Although women are more likely than men to develop the conditions, research suggests that men with giant cell arteritis are more likely to suffer potentially blinding eye involvement. Both conditions almost exclusively affect people over the age of 50. The incidence of both peaks between 70 and 80 years of age.
Polymyalgia rheumatica and giant cell arteritis are both quite common. It is estimated that 711,000 Americans have polymyalgia rheumatica and 228,000 have giant cell arteritis.1
1 Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, et al.; National Arthritis Data Workgroup. Estimates of the Prevalence of Arthritis and Other Rheumatic Conditions in the United States, Part II. Arthritis Rheum. 2008 January ; 58(1): 26?35. doi:10.1002/art.23176
A diagnosis of polymyalgia rheumatica is based primarily on the patient's medical history and symptoms, and on a physical examination. No single test is available to definitively diagnose polymyalgia rheumatica. However, doctors often use lab tests to confirm a diagnosis or rule out other diagnoses or possible reasons for the patient's symptoms.
The most typical laboratory finding in people with polymyalgia rheumatica is an elevated erythrocyte sedimentation rate, commonly referred to as the sed rate. This test measures inflammation by determining how quickly red blood cells fall to the bottom of a test tube of unclotted blood. Rapidly descending cells (an elevated sed rate) indicate inflammation in the body. Although the sed rate measurement is a helpful diagnostic tool, it alone does not confirm polymyalgia rheumatica. An abnormal result indicates only that tissue is inflamed, but this is also a symptom of many forms of arthritis and other rheumatic diseases.
Before making a diagnosis of polymyalgia rheumatica, the doctor may order additional tests. For example, the C-reactive protein test is another common means of measuring inflammation. There is also a common test for rheumatoid factor, an antibody (a protein made by the immune system) that is sometimes found in the blood of people with rheumatoid arthritis. Although polymyalgia rheumatica and rheumatoid arthritis share many symptoms, those with polymyalgia rheumatica rarely test positive for rheumatoid factor. Therefore, a positive rheumatoid factor might suggest a diagnosis of rheumatoid arthritis instead of polymyalgia rheumatica.
As with polymyalgia rheumatica, a diagnosis of giant cell arteritis is based largely on symptoms and a physical examination. The exam may reveal that the temporal artery is inflamed and tender to the touch, and that it has a reduced pulse.
When a doctor suspects giant cell arteritis a temporal artery biopsy is typically ordered. In this procedure, a small section of the artery is removed through an incision in the skin over the temple area and examined under a microscope. A biopsy that is positive for giant cell arteritis will show abnormal cells in the artery walls. Some patients showing symptoms of giant cell arteritis will have negative biopsy results. In such cases, the doctor may suggest a second biopsy.
The treatment of choice for both polymyalgia rheumatica and giant cell arteritis is corticosteroid medication, such as prednisone.2
2 All medicines can have side effects. Some medicines and side effects are mentioned in this publication. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.
Polymyalgia rheumatica responds to a low daily dose of corticosteroids that is increased as needed until symptoms disappear. At this point, the doctor may gradually reduce the dosage to determine the lowest amount needed to alleviate symptoms. Most patients can discontinue medication after 6 months to 2 years. If symptoms recur, corticosteroid treatment is required again.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, also may be used to treat polymyalgia rheumatica. The medication must be taken daily, and long-term use may cause stomach irritation. For most patients, NSAIDs alone are not enough to relieve symptoms.3
3 Warning: Side effects of NSAIDs include stomach problems; skin rashes; high blood pressure; fluid retention; and liver, kidney, and heart problems. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs, because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. NSAIDs should only be used at the lowest dose possible for the shortest time needed.
Even without treatment, polymyalgia rheumatica usually disappears in 1 to several years. With treatment, however, symptoms disappear quickly, usually in 24 to 48 hours. If corticosteroids don’t bring improvement, the doctor is likely to consider other possible diagnoses.
Giant cell arteritis is treated with high doses of corticosteroids. If not treated promptly, the condition carries a small but definite risk of blindness, so corticosteroids should be started as soon as possible, perhaps even before confirming the diagnosis with a temporal artery biopsy.
As with polymyalgia rheumatica, the symptoms of giant cell arteritis quickly disappear with treatment; however, high doses of corticosteroids are typically maintained for 1 month.
Once symptoms disappear and the sed rate is normal, there is much less risk of blindness. At that point, the doctor can begin to gradually reduce the corticosteroid dose.
In both polymyalgia rheumatica and giant cell arteritis, an increase in symptoms may develop when the corticosteroid dose is reduced to lower levels. The doctor may need to hold the lower dose for a longer period of time or even modestly increase it again, temporarily, to control the symptoms. Once the symptoms are in remission and the corticosteroid has been discontinued for several months, recurrence is less common.
Whether taken on a long-term basis for polymyalgia rheumatica or for a shorter period for giant cell arteritis, corticosteroids carry a risk of side effects. Although long-term use and/or higher doses carry the greatest risk, people taking the drug at any dose or for any length of time should be aware of the potential side effects, which include:
- fluid retention and weight gain
- rounding of the face
- delayed wound healing
- bruising easily
- myopathy (muscle wasting)
- increased blood pressure
- decreased calcium absorption in the bones, which can lead to osteoporosis
- irritation of the stomach
- increase in infections.
People taking corticosteroids may have some side effects or none at all. Anyone who experiences side effects should report them to his or her doctor. When the medication is stopped, the side effects disappear. Because corticosteroid drugs reduce the body's natural production of corticosteroid hormones, which are necessary for the body to function properly, it is important not to stop taking the medication unless instructed by a doctor to do so. The patient and doctor must work together to gradually reduce the medication.
Most people with polymyalgia rheumatica and giant cell arteritis lead productive, active lives. The duration of drug treatment differs by patient. Once treatment is discontinued, polymyalgia may recur; but once again, symptoms respond rapidly to prednisone. When properly treated, giant cell arteritis rarely recurs.
Research is providing new information that will help scientists better understand polymyalgia rheumatica and giant cell arteritis. The following issues are being studied:
- Causes and mechanisms. Researchers studying possible causes of polymyalgia rheumatica and giant cell arteritis are investigating the role of genetic predisposition, immune system problems, and environmental factors. Researchers are attempting to better understand the immunobiology of inflamed arteries and advance the understanding of events that initiate vasculitis.
- Prognostic indicators. By examining characteristics of people with and without the conditions, doctors are starting to understand some factors that are associated with both the disease and its prognosis and manifestations. For example, one study has shown that women are more likely than men to have jaw involvement from giant cell arteritis, while men are more likely to have eye involvement that can lead to blindness.
- Treatment. Although treatment with prednisone is almost always effective for both conditions, the drug carries the risk of potentially serious side effects. For that reason, one area of investigation involves looking for treatments that are safe while still being effective. Researchers are exploring treatment regimens that might result in lower doses of oral steroids and control the disease with fewer drug side effects than current regimens.
- Longitudinal information. As part of the NIH-funded Rare Diseases Clinical Research Network, scientists participating in the Vasculitis Clinical Research Consortium are collecting clinical and laboratory information from patients with giant cell arteritis to follow the disease over an extended period of time. Data from these studies will be used to examine the genetics and causes of giant cell arteritis, find new ways to track disease and predict responses, understand how to treat patients, and much more.
More information on research is available from the following resources:
- National Institutes of Health (NIH) Clinical Research Trials and You was designed to help people learn more about clinical trials, why they matter, and how to participate. Visitors to the website will find information about the basics of participating in a clinical trial, first-hand stories from clinical trial volunteers, explanations from researchers, and links on how to search for a trial or enroll in a research-matching program.
- ClinicalTrials.gov offers up-to-date information for locating federally and privately supported clinical trials for a wide range of diseases and conditions.
- NIH RePORTER is an electronic tool that allows users to search a repository of both intramural and extramural NIH-funded research projects from the past 25 years and access publications (since 1985) and patents resulting from NIH funding.
- PubMed is a free service of the U.S. National Library of Medicine that lets you search millions of journal citations and abstracts in the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and preclinical sciences.
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National Eye Institute
National Heart, Lung, and Blood Institute
American College of Rheumatology
American Autoimmune Related Diseases Association, Inc.
National Organization for Rare Disorders
The NIAMS gratefully acknowledges the assistance of the following individuals in the preparation and review of the original version of this publication: Susana Serrate-Sztein, M.D., and Libby Gretz, Ph.D., NIAMS/NIH; Gene G. Hunder, M.D., and Cornelia M. Weyland, M.D., Mayo Clinic, Rochester, MN; and Louis A. Healey, M.D. (retired).
The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the U.S. Department of Health and Human Services' National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The NIAMS Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS website at www.niams.nih.gov.
For Your Information
This publication contains information about medications used to treat the health condition discussed here. When this publication was developed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.
For updates and for any questions about any medications you are taking, please contact
U.S. Food and Drug Administration
Toll free: 888-INFO-FDA (888-463-6332)
For additional information on specific medications, visit Drugs@FDA at http://www.accessdata.fda.gov/scripts/cder/drugsatfda. Drugs@FDA is a searchable catalog of FDA-approved drug products.
For updates and questions about statistics, please contact
Centers for Disease Control and Prevention, National Center for Health Statistics
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Additional copies of this publication are available from:
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
NIH Publication No. 16–4908