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.

Question 2

What condition is strongly associated with Polymyalgia Rheumatica?

Answer 2

Giant Cell Arteritis.

Question 3

Epidemiology of Polymyalgia Rheumatica.

Answer 3

Stereotypical Patient : Caucasian Woman above the Age of 50-60 with a rapid onset (less than 1 month).

Question 4

Core Clinical Features of Polymyalgia Rheumatica (5).

Answer 4

1. Bilateral Shoulder Pain that may radiate to the Elbow.
2. Bilateral Pelvic Girdle Pain.
3. Worse with Movement.
4. Interferes with Sleep.
5. Stiffness for at least 45 minutes in the morning.
   * These should be present for at least 2 weeks.
   ** No weakness!

Question 5

Other Clinical Features of Polymyalgia Rheumatica (4).

Answer 5

1. Systemic Symptoms e.g. Weight Loss, Fatigue, Low-Grade Fever, Low Mood.
2. Upper Arm Tenderness.
3. Carpal Tunnel Syndrome.
4. Pitting Oedema.

Question 6

Investigations of Polymyalgia Rheumatica (2).

Answer 6

1. Inflammatory Markers (e.g. ESR > 40, CRP, Plasma Viscosity) are raised - but normal doesn’t exclude PMR.
2. Diagnosis : Clinical Presentation and Response to Steroids - Exclude other Conditions.

Question 7

Management of Polymyalgia Rheumatica (5).

Answer 7

1. Initial : 15mg Prednisolone Daily (responsive within 72 hours).
2. Assess 1 week after - if poor response : stop and consider alternative diagnosis.
3. Assess 3-4 weeks after : expect 70% improvement in symptoms to continue working diagnosis of PMR.
4. At this point, start a reducing regime with the aim of getting the patient off steroids.
5. If symptoms reoccur whilst on reducing regime, increase dose or stay on dose for longer.

Question 8

Reducing Regime in Polymyalgia Rheumatica (4).

Answer 8

1. 15mg until symptoms are fully controlled.
2. 12.5mg for 3 weeks.
3. 10mg for 4-6 weeks.
4. Reduce by 1mg every 4-8 weeks.
   * It can take 1-2 years to fully wean off.

Question 9

When do you refer to a Rheumatologist? (3)

Answer 9

1. Difficulty controlling symptoms.
2. Difficulty weaning steroids.
3. Steroids are required for 2+ years.

Question 10

Importance of Long-Term Steroid Management (5).

Answer 10

DON’T STOP :
1. Don’t : They should not stop taking as they will be steroid-dependent after 3 weeks - risk of adrenal crisis if steroids are abruptly stopped.
2. S : Sick Day Rules - increase steroid dose if unwell.
3. T : Steroid Treatment Card - alert others that they are steroid dependent.
4. O : Osteoporosis Prevention - consider Bisphosphonates, Calcium, Vitamin D.
5. P : PPI - consider gastric protection.