PMR + GCA

Question 1

Polymyalgia rheumatic

• history
• examination
• investigation

Answer 1

Symmetrical pain and stiffness affecting the shoulder and pelvic girdle

Difficulty rising from a chair unaided and lifting arms up to comb hair

General malaise

Age >50

Examination: unremarkable

Investigations

• routine bloods - usually normal except ESR which is almost always elevated
• Xrays and other imaging unhelpful

Question 2

Polymyalgia rheumatica - treatment

Answer 2

Uncomplicated polymyalgia can be managed in general practice.

Indications for referral to rheumatology are:

• Fails to respond adequately to corticosteroid therapy (wrong diagnosis?).
• Symptoms cannot be controlled with less than 10mg prednisolone daily (for consideration of immunosuppressives)

Management
In a patient with characteristic symptoms and raised ESR:
- Check FBC and ESR before starting steroids
- Prescribe 15-20 mg prednisolone daily
- Arrange review after 1 week, to assess symptomatic response and recheck ESR

In polymyalgia symptoms should have improved dramatically by at least 80% within 2-3 days and ESR should have fallen.
- If does not respond, reconsider diagnosis and/or refer to rheumatology

In patients with good response, gradually reduce steroid dose by approximately 2.5mg per month until daily dose is 10mg, when the rate of dose reduction should be slowed to about 1mg per month until treatment can be withdrawn (typically 1-2 years).

Dose reduction should be titrated against symptoms and ESR (do not treat ESR in absence of symptoms). If symptoms recur and ESR becomes elevated then increase the prednisolone dose by 5mg daily and resume dose reduction at 1mg/month.

Bone protection
Bone protection with oral bisphosphonates should be considered in patients aged >65 that are taking >7.5mg prednisolone for >3 months. In patients <65 DEXA is indicated to determine if bone protection is required (T-score of

Question 3

Polymyalgia rheumatica and giant cell arteritis

Answer 3

Related conditions – most common vasculitis
Shoulder & pelvic girdle pain & stiffness
Age > 55
Headache, visual symptoms
Systemic symptoms

Investigations

• ESR and CRP increased
• Temporal artery biopsy
• inflammation of vessel wall

Question 4

Giant cell arteritis - history

Answer 4

New onset of headache (usually unilateral in the temporal area, but can be bilateral)

Jaw claudication (pain over masseter muscles on chewing)

Tenderness or pain over scalp.

Visual disturbance

Symmetrical pain and stiffness affecting the shoulder and pelvic girdle

Difficulty rising from a chair unaided and lifting arms up to comb hair

General malaise

Age >50

Question 5

Giant cell arteritis - examination

Answer 5

Usually unremarkable

Occasionally focal tenderness and thickening over temporal artery

Visual field defects or reduced visual acuity

Question 6

Giant cell arteritis - investigations

Answer 6

Routine bloods (mild anaemia; ESR and CRP almost always elevated)

Temporal artery biopsy - organised through rheumatology referral or ophthalmology in patients with visual symptoms.
Only positive in about 50%.
Negative result does not exclude diagnosis.

Question 7

Giant cell arteritis - when is referral needed?

Answer 7

Patients with uncomplicated classical GCA can be managed in GP but if there is doubt about diagnosis or complications develop referral is needed.

Definite indications for referral are:

• Unusual presentation (suggestive symptoms but normal ESR, patient under 50 years)
• Patient fails to respond adequately to corticosteroid therapy (suggests diagnosis is wrong).
• Symptoms cannot be controlled with < 10mg prednisolone daily (for consideration of immunosuppressives).

Question 8

Giant cell arteritis - immediate management

Answer 8

In a patient with characteristic symptoms of CGA and raised ESR, high dose corticosteroids are indicated.

Corticosteroid treatment should not be delayed pending clinic review or while awaiting a temporal artery biopsy.

• Check FBC and ESR before starting steroids
• Prescribe 40-60mg prednisolone daily (not less than 0.75mg/kg/day)

Arrange review after 1 week, review symptoms and recheck FBC and ESR

If diagnosis of GCA is correct symptoms should have improved dramatically within 2-3 days and ESR should have fallen.

Question 9

Giant cell arteritis - long-term management

Answer 9

Continue initial dose of prednisolone for 4 weeks until symptoms have improved.
Thereafter the dose should be gradually reduced by 10mg every two weeks until the daily prednisolone dose is 20mg.
At this point slow the rate of dose reduction to 2.5 mg every 2 weeks until the daily prednisolone dose is 10mg.
Then reduce by 1mg/month until steroids can be withdrawn.

The dose reduction should be titrated against symptoms and ESR (do not treat ESR in absence of symptoms). If symptoms recur and ESR becomes elevated then increase prednisolone dose to the one that was last controlling symptoms and resume the programme of dose reduction.

Question 10

What is giant cell arteritis?

Answer 10

Common form of vasculitis in people >50

Granulomatous vasculitis of large and medium-sized arteries

Extracranial branches of carotid artery usually affected

More common in women

Symptoms of polymyalgia rheumatic frequently present

Most common serious consequence: irreversible blindness

Long term complication: aortic aneurysm and large vessel stenoses