Polymyalgia Rheumatica

Question 1

Define polymyalgia rheumatica (PMR)

Answer 1

• An inflammatory condition that causes pain and stiffness in the shoulder, pelvic girdle, and neck.

Question 2

what is PMR associated with ?

Answer 2

giant cell arteritis

Question 3

RF for PMR

Answer 3

• Older age
• Female
• Northern European
• Infection

Question 4

core features which need to be present for >2 weeks.

Answer 4

1) Bilateral shoulder pain that radiates to the elbow
2) Bilateral pelvic girdle pain
3) Worse with movement
4) Interferes with sleep
5) Stiffness for at least 45 mins in the morning

Question 5

systemic features of PMR

Answer 5

• Weight loss
• Fatigue
• Low grade fever
• Low mood
• Upper arm tenderness
• Carpal tunnel
• Pitting oedema

Question 6

DDx to consider for PMR

Answer 6

• OA
• RA
• SLE
• Myositis
• Cervical spondylosis
• Adhesive capsulitis of both shoulders
• Hyper/hypothyroidism
• Osteomalacia
• Fibromyalgia

Question 7

how would you diagnose PMR?

Answer 7

• Clinical presentation + response to steroids
• ESR and CRP may be raised but cannot exclude PMR with normal inflammatory markers.
• FBC/ U+Es/ LFTs/ Ca2+ (varies from hyper PTH/Ca/osteomalacia)/ serum protein electrophoresis (myeloma)/ TSH/ CK/ Rheumatoid factor/ urine dip.

Question 8

what antibodies might you do to exclude ddx for PMR?

Answer 8

1) Do an ANA for SLE
2) Anti-CCP for RA
3) Urine bence jones protein for myeloma
4) CXR for lung and mediastinal abnormalities

Question 9

management of PMR?

Answer 9

1) Initially: start on 15mg pred/OD
2) Assess 1 week (poor response  not PMR thus stop steroids)
3) Assess 3-4 weeks after (70% improvement in sx and inflammatory markers normal to make a working dx of PMR)
4) If 3-4 weeks, improvement then reduce regime by weaning patient off steroids.
- 15mg until sx controlled
- 12.5mg for 3 weeks
- 10 mg for 4-6 weeks
- Reduce by 1mg every 4-6 weeks

Question 10

when would you refer to a rheum dr for PMR?

Answer 10

• If sx reoccur, then may need to increase dose or stay on dose for much longer before reducing.
• If requiring steroids for >2 years or when weaning off steroids, patient is relapsing then refer to rheumatologist.

Question 11

what to advise for patients on long term steroids? (DONT STOP)

Answer 11

1) DON’T – should not stop after 3 weeks of Rx as may cause adrenal crisis
2) Sick day rules (increase dose of steroid if unwell)
3) Treatment card
4) Osteoporosis (maybe give bisphosphonates and calcium and vitamin D supplements)
5) PPI