Polymyalgia Rheumatica and Giant Cell Arteritis Explained

  By Dr Kate Celkys and Dr Simran Kaur, Rheumatologists 

Polymyalgia Rheumatica (PMR) and Giant Cell Arteritis (GCA) are closely related inflammatory conditions that primarily affect adults over 50. Experiencing sudden symptoms can feel concerning, but understanding these conditions can help you feel more informed, reassured, and confident in managing your health. Rheumatologists Dr Simran Kaur and Dr Kate Celkys explain how PMR and GCA differ, where they overlap, and what treatment and long-term management can involve, giving you practical insights to support your care.

Polymyalgia Rheumatica (PMR)

PMR is an inflammatory condition affecting the linings of joints, bursae, and tendons rather than the muscles themselves, though it can feel muscular. It most commonly affects adults aged 70–80 and is slightly more common in women. The classic features include severe stiffness and pain in the shoulders, hips, and neck, particularly in the morning, often accompanied by fatigue, low-grade fevers, reduced appetite, or weight loss. Blood tests usually show elevated inflammatory markers such as ESR and CRP.

Morning stiffness is a defining symptom. Inflammatory cytokines, including IL-6, peak overnight while cortisol, the body’s natural steroid hormone, is at its lowest. Movement helps “lubricate” inflamed tissues, so stiffness often improves as the day goes on. This pattern helps distinguish PMR from osteoarthritis, where stiffness tends to be shorter-lived and less severe.

The exact cause of PMR is unknown, but age-related changes in the immune system, genetic susceptibility, and environmental triggers likely play a role. PMR does not increase the risk of premature death or cause permanent joint damage. However, if left untreated, it can be debilitating, leading to loss of strength, reduced mobility, and difficulties in daily activities. Untreated PMR also increases the risk of developing GCA, a more serious related condition.

Diagnosis is primarily clinical, supported by blood tests, imaging, and exclusion of other conditions such as rheumatoid arthritis, myopathy, infection, or malignancy. A rapid response to low-to-moderate dose corticosteroids—typically within 24–72 hours—strongly supports the diagnosis. If improvement does not occur within a week, the diagnosis may need to be reconsidered.

Treatment of PMR

Prednisolone is the mainstay of treatment. Initial doses are usually 15–25 mg daily, with rapid improvement often seen within days. Tapering generally occurs gradually over 12–24 months, guided by symptoms and blood tests. Steroid-sparing medications like methotrexate may be introduced if relapses occur or side effects are problematic. The goal is always the lowest effective steroid dose to minimise long-term risks.

Living well during treatment involves more than medication. You can support your recovery and reduce relapses by:

🟡  Doing graded strengthening and mobility exercises
🟡 Avoiding prolonged periods of inactivity
🟡 Pacing yourself to manage fatigue
🟡 Maintaining a diet rich in omega-3 fatty acids, calcium, and vitamin D
🟡 Reducing stress where possible
🟡 Stopping smoking
🟡 Leaning on support networks, including your GP, rheumatologist, and allied health team

Around 30–50% of people experience relapses within the first year, but these are generally manageable and do not mean your condition is severe or permanent.

Giant Cell Arteritis (GCA)

GCA is part of the same disease spectrum as PMR, affecting medium- and large-sized arteries, most famously the temporal arteries, but also potentially the aorta, neck arteries, and arteries supplying the arms and legs. About 10–20% of people with PMR develop GCA, while 40–60% of people with GCA experience PMR symptoms. Like PMR, GCA almost exclusively affects adults over 50.

GCA is serious because it can reduce blood flow to critical organs, particularly the eyes and brain. Key symptoms include new-onset headaches, jaw fatigue or pain when chewing, scalp tenderness, and visual disturbances such as blurred or double vision. Some patients primarily present with large-vessel disease, experiencing limb fatigue, asymmetrical pulses, or chest and back pain. Visual symptoms are medical emergencies, making early recognition critical.

Investigations may include elevated ESR and CRP, anaemia, raised platelets, ultrasound of temporal and neck arteries, MRI or CT angiography, FDG-PET CT, and sometimes temporal artery biopsy. Treatment should never be delayed while awaiting biopsy if suspicion is high.

Management of GCA

Immediate treatment is guided by clinical suspicion alone. High-dose oral prednisone—up to 60 mg daily—or intravenous methylprednisolone if visual symptoms are present is standard. In selected cases, aspirin may be recommended, alongside infection screening and bone health assessment. Longer-term management involves gradual steroid tapering over months to years, often with the addition of steroid-sparing therapies such as tocilizumab to reduce relapse rates and cumulative steroid exposure. Relapses are common, particularly within the first 1–2 years, and are managed by adjusting steroid doses or adding adjunctive therapy.

Long-Term Outlook

For many, both PMR and GCA are self-limiting, though some patients experience a chronic relapsing course requiring ongoing monitoring. In GCA, chronic inflammation of large arteries can lead to serious complications such as aortic aneurysm or dissection. Long-term follow-up also focuses on minimising steroid-related complications, including osteoporosis, diabetes, and infection risk.

Key Takeaways

PMR and GCA are inflammatory conditions affecting adults over 50. PMR causes severe shoulder and hip stiffness but is highly treatable and does not cause joint damage. GCA affects arteries and can threaten vision, requiring urgent intervention. Both conditions are primarily managed with corticosteroids over months to years, and relapses are common but manageable. Treatment aims not just to control inflammation but to preserve strength, independence, and quality of life. With early recognition, appropriate treatment, and ongoing monitoring, most people regain baseline function and continue living full, active lives.

This article is based on Dr Simran Kaur and Dr Kate Celkys’ discussion of Polymyalgia Rheumatica and Giant Cell Arteritis. You can access the full session and hear their complete insights by watching the full talk here. 

References:

• Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Schett G, Schulze-Koops H, Spiera R, Unizony SH, Collinson N. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017 Jul 27;377(4):317-328. doi: 10.1056/NEJMoa1613849. PMID: 28745999.
  
• Ponte C, Grayson PC, Robson JC, Suppiah R, Gribbons KB, Judge A, Craven A, Khalid S, Hutchings A, Watts RA, Merkel PA, Luqmani RA; DCVAS Study Group. 2022 American College of Rheumatology/EULAR Classification Criteria for Giant Cell Arteritis. Arthritis Rheumatol. 2022 Dec;74(12):1881-1889. doi: 10.1002/art.42325. Epub 2022 Nov 8. PMID: 36350123.