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Polymyalgia rheumatica — MCCQE Part 1 MCQ

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HardJoint PainPolymyalgia rheumaticaMCCQE Part 1

A 60-year-old woman has 2 months of bilateral shoulder- and hip-girdle aching with morning stiffness lasting 90 minutes. ESR is 65 mm/h, CRP 48 mg/L and creatine kinase is normal. Rheumatoid factor and anti-CCP are negative, and there is no objective muscle weakness or peripheral synovitis. She denies new headache, scalp tenderness, jaw claudication and visual symptoms. What is the most appropriate initial treatment?

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Correct answer: A — Start prednisone 15 mg daily with a planned taper

The age, bilateral shoulder and hip symptoms, prolonged morning stiffness, elevated inflammatory markers and normal creatine kinase support polymyalgia rheumatica after reasonable exclusion of mimics. Initial treatment is low-dose oral prednisone; 15 mg daily lies within the cited 12.5–25 mg starting range. Symptoms often improve within 24–72 hours, but response supports rather than proves the diagnosis, so an atypical or incomplete response requires reassessment. High-dose prednisone is used when giant-cell arteritis is suspected, especially with visual or cranial ischaemic symptoms, which are absent here. Methotrexate may be added in selected relapsing or glucocorticoid-risk cases but is not usual initial monotherapy. Bone, metabolic and infection risks should be assessed and the glucocorticoid tapered according to clinical and inflammatory-marker response.

Reference: CMAJ, Polymyalgia rheumatica: https://www.cmaj.ca/content/193/46/E1770