PMR

Question 1

What is the presentation of PMR?

Answer 1

Pain and stiffness in the shoulders, pelvic girdle and neck

Strongly associated with GCA

Symptoms present for at least two weeks:

• Pain worse with movement
• Often interferes with sleep
• Stiffness for at least 45 minutes in the morning

Also can present with:
- Systemic symptoms e.g. weight loss, fatigue, low grade fever and low mood

Question 2

Demographics of patients typically affected by PMR

Answer 2

It usually affects old adults (above 50 years)

More common in women

More common in Caucasians

Question 3

Differential diagnoses for PMR

Answer 3

Osteoarthritis
Rheumatoid arthritis

Systemic lupus erythematosus

Myositis (from conditions like polymyositis or medications like statins)

Cervical spondylosis

Adhesive capsulitis of both shoulders

Hyper or hypothyroidism
Osteomalacia
Fibromyalgia

Question 4

Investigations in suspected PMR

Answer 4

NICE suggested Investigations before steroids:

• Full blood count
• CRP and ESR (usually raised in PMR but can be normal)
• Urea and electrolytes
• Liver function tests
• Rheumatoid factor for rheumatoid arthritis

Calcium can be raised in hyperparathyroidism or cancer or low in osteomalacia

Serum protein electrophoresis for myeloma and other protein disorders

Thyroid stimulating hormone for thyroid function

Creatine kinase for myositis

Urine dipstick

Question 5

Diagnosis and treatment of PMR

Answer 5

Trial of 15mg prednisolone OD

Review after a week and if there isn’t marked improvement it is probably not PMR, so stop steroids and consider other diagnoses

If good steroid response continue for 3-4w total, then taper off

Question 6

Important safety information and advice for patients on steroids

Answer 6

mnemonic “Don’t STOP”:

DON’T – Make them aware that they will become steroid dependent after 3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn
S – Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”)
T – Treatment Card: to alert others that they are steroid dependent for if become unresponsive
O – Osteoporosis prevention: Consider osteoporosis prophylaxis with bisphosphonates and calcium and vitamin D supplements
P – Proton pump inhibitor: Consider gastric protection with PPI