Polymyalgia Rheumatica

Why Is This Happening to Me?
How Will I Feel?
What Do I Need to Do?
Will I Always Have This?
Saving Money on Drugs
Additional Resources

Why Is This Happening to Me?
The term polymyalgia comes from the Greek poly (many), myo (muscle) and algia (pain). This condition is a form of arthritis that causes pain in the muscles of the lower back, thighs, hips, neck, shoulder and upper arms, as well as in other parts of the body. It arises when the membrane that surrounds the joints, bursa and tendons near the shoulders and hips (called the synovium) becomes inflamed. Although the disease is centered on the joints (especially the shoulders and hips), the discomfort is experienced in the upper arms and thighs because the pain is "referred" (that is, it arises in one area but causes symptoms in another).

Typically, polymyalgia rheumatica affects people older than 55, with slightly more women affected than men. Left untreated, it can lead to stiffness and significant disability. In some cases, though, symptoms do not advance and may even dissipate in a few years. In a minority of cases, polymyalgia rheumatica is associated with giant cell arteritis a condition in which blood vessels in the neck and head, and sometimes elsewhere, are inflamed. If left untreated, giant cell arteritis can lead to blindness or other complications.

How Will I Feel?
The typical symptoms of polymyalgia rheumatica (PMR) include:

Your doctor will diagnose this condition based in large part on how you feel; your physical examination is important to look for other causes of your symptoms.  Certain symptoms, such as headache, jaw pain with chewing or high fever, may suggest the presence of giant cell arteritis. A blood test measures inflammation throughout the body. This test, called the erythrocyte sedimentation rate (ESR), is often elevated in people with polymyalgia rheumatica. This test may be helpful for diagnosis and to check whether treatment is working.

What Do I Need To Do?
Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin and others) or naproxen (Aleve, Naprosyn) often are tried, effective therapy of polymyalgia rheumatica usually requires corticosteroids (such as prednisone). Low doses (10 to 15 milligrams per day) are highly effective with prompt reduction in dosage within a few days; slow reductions in dosage (called “tapers”), sometimes by only 1 mg per month, are typically recommended.

Physical therapy also may be helpful in controlling discomfort and maintaining mobility and function. For people who are unable to taper the corticosteroids or who have significant side effects, other agents such as hydroxychloroquine (Plaquenil) or methotrexate are often prescribed. Additional medications to prevent side effects of prednisone also may be prescribed. For example, alendronate (Fosamax) may be prescribed to prevent osteoporosis.

Because the cause of polymyalgia rheumatica is not known, there is no known way to prevent it.

Will I Always Have This?
Without treatment, polymyalgia rheumatica sometimes goes away on its own over a period of several years. With treatment, symptoms are controlled within days, but treatment is generally necessary for a prolonged period (at least six months and often one to two years) because symptoms tend to come back as treatment is reduced or ended.  Although treatment may be required for years, the overall prognosis for people with polymyalgia rheumatica is excellent.

For the small subset of people with giant cell arteritis that begins as polymyalgia rheumatica, loss of vision in one eye (or even more rarely, in both eyes) may occur, especially if treatment is delayed. Side effects of the medications used to treat giant cell arteritis account for most of the problems associated with this illness, rather than the disease itself.

Saving Money on Drugs
Drug therapy for PMR is aimed at reducing pain and improving function. The best way to get the most from your health care dollar is to understand the disease and the treatment being prescribed. It is important to be both compliant (taking the drugs in the way they are prescribed) and persistent (taking them routinely and not missing doses) to get the most benefit. On the other hand, taking the lowest effective dose of any medication makes sense both to reduce side effects and to reduce cost.

You should discuss drug therapy options with your physician. Be candid about your ability to pay for the therapies and whether your health insurance covers all or part of your medication costs. Because of the range of therapies available, your physician has the ability to tailor your drug therapy to match your level of disease and in many cases, your pocketbook.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
As mentioned above, NSAIDs are typically among the initial treatments for PMR. On average, all of the NSAIDs work equally well when taken in equivalent doses. Many NSAIDs including Motrin, Aleve and others can be purchased over the counter (OTC), that is, without a prescription.  The prescription versions often (but not always) contain a higher dose of drug in each tablet or capsule than the OTC products. A generic version is available for many of the NSAIDs for both the prescription and OTC products; the only difference is cost.

Here’s an example:

OTC naproxen comes in a 220mg tablet (sold as a store brand and as Aleve). The prescription version naproxen (sold as a generic or under the brand name Naprosyn and others) is available in a 250mg, 375mg and a 500mg tablet. A typical dose for persons with PMR is 250mg to 500mg twice a day. 

Drug

Est. Daily Cost

Aleve 220mg. Two tablets twice a day.

$0.40

Naproxen 220mg (store brand). Two tablets twice each day.

$0.25

Naprosyn 500mg. One tablet twice each day.

$3.25

Naproxen 500mg (generic). One tablet twice each day.

$0.60

Note: The doses listed are those normally used when the drug is taken by prescription. These doses are higher than those that are on the label of Aleve and the generic over the counter version. The dose of naproxen is lower with the OTC version than the prescription version (880 mg vd.1000 mg). Ask your doctor about taking the OTC version because the dose is not exactly the same as the prescription version. Also, even though the OTC costs are lower in this example, your out-of-pocket costs may be lower using a prescription if you have insurance coverage for prescription drugs.

Although, on average, all of the NSAIDs work equally well (when taken in the comparable doses), some people seem to respond better to one than another. The reason for this is not known and is not predictable. All have similar side effects, but there are rather large differences in price. Before your physician prescribes a NSAID, ask him or her about the options and tradeoffs. Some of the NSAIDs can be taken once a day (such as Lodine XL, Naprelan and others) but they come at a premium price when compared to ibuprofen that needs to be taken 3-4 times a day. A good compromise in both price and convenience is a generic version of naproxen. It is taken twice a day and is among the least expensive of all NSAIDs (approximately $7.50/month for generic, OTC naproxen).

The newest NSAIDs, COX-2 inhibitors (they selectively inhibit the enzyme, COX-2) have a reduced risk of stomach damage, particularly for those who have higher than average risk of stomach ulcers (including those who have had ulcers in the past, those taking corticosteroid medications and the elderly). They work about as well as the older NSAIDs. Celecoxib (Celebrex) is currently the only COX-2 inhibitor still available, as valdecoxib (Bextra) and rofecoxib (Vioxx) have been withdrawn from the market due to concerns about their cardiovascular safety. You can expect to pay between $2.50 and $5.00 per day for these medicines. Most experts do not recommend these medications for persons at average or low risk of ulcers because their high price does not seem to justify their modest benefits. Concerns about the cardiovascular safety of these agents were raised when researchers noted an increased risk of heart attack and stroke among people taking rofecoxib (Vioxx). As a result, rofecoxib was withdrawn from the market; studies of celecoxib and valdecoxib are ongoing.

Here are some other general recommendations to help keep your health care costs under control:

  1. Always ask your health care provider to prescribe the generic form of the drug if there is one available. Generic drugs work just as well as brand-name drugs. The U.S. Food and Drug Administration has a strict set of rules that drug producers must live by. These rules for quality apply to both the brand-name maker and the generic maker of prescription drugs. The difference in price can be very large, and there is no difference in how well they work.
  2. If you are taking prescription drugs for a chronic condition like PMR, think about getting a three-month supply at a time, and consider using a mail-order pharmacy. The co-payments are usually less if your have prescription-drug coverage in your health insurance. Many online pharmacies offer discounts for a three-month supply. Some managed-care insurance companies limit your choices of mail order pharmacies. If you have a choice, always look for one, especially an internet pharmacy, with a VIPPS seal of approval, issued by the National Association of Boards of Pharmacy.
  3. Pill splitting is sometimes a good way to reduce your costs. Ask your pharmacist about tablet strength. Getting a tablet in twice the dose and cutting it in half can sometime reduce your cost by as much as one-half. Not all tablets can be split. A good rule of thumb is to look for a scoring on the tablet.
  4. Most health insurance plans have a preferred list of drugs. Many will penalize consumers by making them pay a larger co-payment for non-preferred drugs, or not covering the drug at all. Ask your health care provider to prescribe drugs that are on your insurance company's preferred list.
  5. Keep in mind that many complementary and alternative therapies are not covered by insurance and may require significant out of pocket expense.
  6. Many insurance plans will cover referrals to other practitioners (such as physical therapists or spine specialists) only if approved by your primary care physician.  In addition, your cost may be higher if you see providers outside of your primary care physician’s network. So, before making appointments, check with your primary care physician and/or your insurance company for details about how best to get ideal care at the lowest cost.
  7. Ask your pharmacist about less expensive drug options. He or she is in the best position to know which drugs can save you money.

Additional Resources
American College of Rheumatology
http://www.rheumatology.org/

Arthritis Foundation
http://www.arthritis.org/

Last Updated September 2003
Copyright 2004, Harvard Medical School, Harvard University.