Polymyalgia Rheumatica

Question 1

what is polymyalgia rheumatica?

Answer 1

an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck

strong association with giant cell arteritis

(women, >50’s, caucasians)

Question 2

what are the core features of PR?

Answer 2

bilateral shoulder pain that can radiate to the elbow
bilateral pelvic girdle pain
worse with movement
interferes with sleep
stiffness lasts >45 minutes in the morning

systemic symptoms- weight loss, fatigue, low grade fever, low mood

upper arm tenderness
carpal tunnel syndrome
pitting oedema

Question 3

differential diagnosis for PR

Answer 3

Osteoarthritis
Rheumatoid arhtirits
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

how to diagnose PR?

Answer 4

clinical presentation and response to steroids

bedside:
urine dipstick

bloods:
inflammatory markers- ESR, CRP, plasma viscocity
FBC, U+E, LFT
Ca2+ (hyperparathyroidism, osteomalacia)
TSH
CK (myositis)

special
serum protein electrophoresis
myeloma
ANA (SLE)
anti CCP (RA)
urine Bence Jones protein (myeloma)

imaging:
chest XRAY

Question 5

what is the treatment for PR?

Answer 5

intiially- 15mg prednisone per day

assess 1 week after - if poor response then probably not PMR, stoma steorids

assess 3-4 weeks. expect a 70% improvement and inflammatory markers should return to normal

Question 6

reducing regime for PR steroids

Answer 6

(prednisolone)

15mg until symptoms are fully controlled then
12.5mg for 3 weeks then
10mg for 4-6 weeks then
Reduce by 1mg every 4-8 weeks

if symptoms recur- increase dose / stay on dose and can take 1-2 years to fully wean off

Question 7

DON’T STOP

Answer 7

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3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn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: Provide a steroid treatment card to alert others that they are steroid dependent in case they become unresponsive

O – Osteoporosis prevention: Consider osteoporosis prophylaxis whilst on steroids with bisphosphonates and calcium and vitamin D supplements

P – Proton pump inhibitor: Consider gastric protection with a proton pump inhibitor (e.g. omeprazole)