MSK: Polymyalgia Rheumatica, Fibromyalgia & Osteoporosis Flashcards
What is polymyalgia rheumatica (PMR)?
An inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck.
Polymyalgia rheumatica (PMR) has a strong association with which condition?
Giant cell arteritis (the two conditions often occur together)
Cause of PMR?
Not fully understood
Who is PMR more common in?
Older white patients
Onset of symptoms of PMR?
Often relatively rapid onset (over days to weeks)
Symptoms of PMR?
Pain and stiffness of the:
1) Shoulders, potentially radiating to the upper arm and elbow
2) Pelvic girdle (around the hips), potentially radiating to the thighs
3) Neck
How long must the symptoms be present for for a PMR diagnosis to be made?
2 weeks
Describe the characteristic features of the pain and stiffness in PMR
1) Worse in the morning
2) Worse after rest or inactivity
3) Interfere with sleep
4) Take at least 45 minutes to ease in the morning
5) Somewhat improve with activity
When is PMR pain and stiffness worse?
1) in morning
2) after rest or inactivity
What are some associated features seen in PMR?
- Systemic symptoms (e.g., weight loss, fatigue and low-grade fever)
- Muscle tenderness
- Carpel tunnel syndrome
- Peripheral oedema
What are the 2 key symptoms of PMR?
pain and stiffness
Give some differentials for PMR (as presenting symptoms are not specific)
- OA
- RA
- SLE
- Statin-induced myopathy
- Myositis (e.g., polymyositis)
- Fibromyalgia
- Lymphoma or leukaemia
- Myeloma
- Adhesive capsulitis (frozen shoulder)
- Osteomalacia
- Hyperthyroidism or hypothyroidism
How is diagnosis of PMR made?
Diagnosis is based on clinical presentation, response to steroids and excluding differentials.
What investigations are advised in PMR?
- FBC
- CRP & ESR (inflammatory markers usually raised but may be normal)
- Renal function (U&Es)
- LFTs
- Calcium (abnormal in hyperparathyroidism, cancer and osteomalacia)
- Serum protein electrophoresis for myeloma
- Thyroid-stimulating hormone for thyroid function
- Creatine kinase for myositis
- Rheumatoid factor for rheumatoid arthritis
- Urine dipstick
What investigations can be done to rule out RA as a differential in PMR?
RF & anti-CCPs
What investigation can be done to rule out SLE as a differential in PMR?
Anti-nuclear antibodies (ANA)
What investigations can be done to rule out myeloma as a differential in PMR?
Serum protein electrophoresis and Urine Bence Jones protein
What antibodies are seen in SLE?
Anti-nuclear antibodies (ANA)
What antibodies are seen in RA?
Anti-CCP and RF
Pharmacological management of PMR?
Steroids
What dose of steroids is given in PMR?
15mg prednisolone daily initially
Follow up after 1 week
What is the response to steroid treatment in PMR?
Patients with PMR have a dramatic improvement in symptoms (at least 70%) within one week.
Inflammatory markers return to normal within one month.
What does a poor response to steroids in PMR suggest?
Alternative diagnosis
How long does treatment with steroids in PMR last?
Treatment with steroids typically lasts 1-2 years.
Describe how dose of steroids changes in PMR
NICE suggest the following reducing regime of prednisolone:
1) 15mg until the symptoms are fully controlled, then
2) 12.5mg for 3 weeks, then
3) 10mg for 4-6 weeks, then
4) Reducing by 1mg every 4-8 weeks
The reducing regime can go faster or slower depending on the individual and their symptom control.
Management for patients on long-term steroids can be remembered with ‘DONT STOP’ pneumonic.
What is this?
Dont stop steroids abruptly due to risk of adrenal crisis.
S - S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)
What should be consdiered to prescribe alongside long-term steroids?
1) PPIs for gastric protection
2) Osteoporosis protection e.g. vit D, bisphosphonates, calcium
How should steroid dose be changed in patients who become unwell (sick day rules)?
May need to increase dose
What is fibromyalgia?
A syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites.
The cause of fibromyalgia is unknown.
Are men or women more likely to be affected by fibromyalgia?
Women (5x)
Typical age of fibromyalgia presentation?
30-50 years old
Features of fibromyalgia?
1) chronic pain: at multiple site, sometimes ‘pain all over’
2) lethargy
3) cognitive impairment: ‘fibro fog’
4) sleep disturbance, headaches, dizziness are common
Diagnosis is clinical and sometimes refers to the American College of Rheumatology classification criteria.
This criteria lists 9 pairs of tender points on the body.
What score indicates fibromyalgia?
If a patient is tender in at least 11 of these 18 points
Management of fibromyalgia?
Often difficult and needs to be tailored to the individual patient.
Needs psychosocial and multidisciplinary approach.
1) explanation
2) aerobic exercise: has the strongest evidence base
3) cognitive behavioural therapy
4) medication: pregabalin, duloxetine, amitriptyline
What 3 medications can be used in fibromyalgia?
1) pregabalin
2) duloxetine
3) amitriptyline
What is osteoporosis?
Osteoporosis involves a significant reduction in bone density.
What is osteopenia?
Osteopenia refers to a less severe decrease in bone density.
What is used to diagnose osteoporosis/osteopenia?
T score of the femoral neck measured on a DEXA scan: T-score is the number of standard deviations the patient is from an average healthy young adult.
What does a T score of -1 mean?
A T-score of -1 means the bone mineral density is 1 standard deviation below the average for healthy young adults.
What T score is normal?
More than -1
What T score defines osteopenia?
-1 to -2.5
What T score defines osteoporosis?
Less than -2.5
What T score defines severe osteoporosis?
Less than -2.5 plus a fracture
What is used to measure bone mineral density?
DEXA scan
What is a DEXA scan?
DEXA scans are a type of x-ray that measures how much radiation is absorbed by the bones, indicating how dense the bone is.
What area of the body is most important to measure bone density?
Femoral neck
Bone density can be represented as a Z-score or T-score.
What is a Z score?
What is a T score?
The Z-score is the number of standard deviations the patient is from the average for their age, sex and ethnicity.
The T-score is the number of standard deviations the patient is from an average healthy young adult (used for diagnosis)
Risk factors for osteoporosis?
- Older age
- Post-menopausal women
- Reduced mobility & activity
- Low BMI (<19)
- Low calcium or vit D intake
- Alcohol or smoking
- Personal or FH of fractures
- Chronic diseases e.g. CKD, hyperthyroidism, RA
- Long term corticosteroids (e.g. 7.5mg or more of prednisolone daily for longer than 3 months)
- Certain medications e.g. SSRIs, PPIs, anti-epileptics, anti-oestrogens
- Prolonged PPI use
Impact of tamoxifen on osteoporosis?
Tamoxifen is a selective oestrogen receptor modulator (SERM).
It blocks oestrogen receptors in breast tissue but stimulates oestrogen receptors in the uterus and bones: it helps prevent osteoporosis but increases the risk of endometrial cancer.
What is a SERM used to treat osteoporosis?
Raloxifene
Who is recommended for assessment for osteoporosis?
1) Anyone on long-term oral corticosteroids or with a previous fragility fracture
2) Anyone 50 and over with risk factors
3) All women 65 and over
4) All men 75 and over
How can the 10-year risk of a major osteoporotic fracture and a hip fracture be calculated?
1) QFracture tool (preferred by NICE)
2) FRAX tool (NICE say this may underestimate the risk in some patients)
What QFracture score are patients considered for a DEXA scan?
Above 10%
Lifestyle mangement of osteoporosis?
Address reversible risk factors e.g. increase physical activity, maintain a healthy weight, stop smoking and reduce alcohol consumption.
Medical management of osteoporosis?
1) Address insufficient intake of calcium (less than 700mg per day)
2) Address insufficient intake of vitamin D
3) Bisphosphonates
Side effects of bisphosphonates?
1) Reflux and oesophageal erosions
2) Atypical fractures (e.g., atypical femoral fractures)
3) Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
4) Osteonecrosis of the external auditory canal
How should oral bisphosphonates be taken?
Oral bisphosphonates are taken on an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.
Give 3 examples of bisphosphonates
1) Alendronate 70 mg once weekly (oral)
2) Risedronate 35 mg once weekly (oral)
3) Zoledronic acid 5 mg once yearly (intravenous)
When should treatment with bisphosphonates be assessed?
After 3-5 years
They suggest a repeat DEXA scan and stopping treatment if the T-score is more than -2.5. Treatment is continued in high-risk patients.
Give some specialist options for treating osteoporosis (where bisphosphonates are not suitable)
Denosumab: a monoclonal antibody that targets osteoclasts
Romosozumab: a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation
Teriparatide: acts as parathyroid hormone
Hormone replacement therapy: particularly in women with early menopause
Raloxifene: a selective oestrogen receptor modulator
Strontium ranelate: a similar element to calcium that stimulates osteoblasts and blocks osteoclasts
Notable risks of Strontium ranelate?
Increases risk of VTE and MI
Notable risks of raloxifene?
venous thromboembolism risk
