Polymyalgia Rheumatica Flashcards
Define PMR
Polymyalgia Rheumatica
inflammatory disease causing pain and stiffness in the shoulder, neck and pelvic girdle.
What are the RF for PMR?
- Adults, > 50 yrs
- Women
- Caucasian
How does PMR present?
- Features presents for > 2wks:
o Bilateral shoulder pain that may radiate to the elbow
o Bilateral pelvic girdle pain
o Worse with movement
o Interferes with sleep
o Stiffness for at least 45 minutes in the morning - Other symp:
o Systemic symp – weight loss, fatigue, fever, low mood.
o Peripheral arthritis
o Carpal tunnel syn
o Pitting oedema – hand, wrists, feet and ankles.
o Upper arm tenderness
How is PMR diagnosed?
- diagnosis of exclusion.
- also based on starting trial of steriod and pos response to Tx.
- ESR and CRP will be raised (but normal does not exclude diagnosis).
order various tests to exclude other diagnoses, e.g:
o FBC – incl U+E, LFT, TFT, RF (rheumatioid arthiritis)
o Creatine kinase for myostisis
o Serum protein electrophoresis for myeloma and other protein disorders
o Ca2+ - raised in hyperparathyroidism and cancer, or low in osteromalacia.
o Urine dip
o Anti-nuclear antibodies (ANA) for systemic lupus erythematosus
o Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
o Urine Bence Jones protein for myeloma
o Chest Xray for lung and mediastinal abnormalities
ALSO RULE OUT GIANT CELL ARTERITIS - MOST IMPORTANT
In someone with suspected PMR why is it important to exclude giant cell arteritis?
Giant cell arteritis - need to start steroid straight away.
but not in PMR - allows time for workup before starting steroid tx.
How would you diffn PMR and myositis?
- Myositis causes bilateral proximal muscle weakness, but there is not pain/ mild pain.
- WHEREAS in PMR – lots of pain and stiffness BUT no muscle weakness on exam (but can be difficult to confirm as movement limited to pain).
How is PMR managed?
Initially give trial of oral prednisolone, 15mg OD – follow up after 1 wk.
o If there has been no improvement in symp – mostly likely not PMR – STOP steriods and consider DDx.
o If good respose, re-check again after 3-4 wks – symp should have resolved and inflammatory markers should have come back down to normal.
If 3-4 weeks of steroids has given a good response then start a reducing regime with the aim of getting the patient off steroids:
* 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
What is included in the patient workup before starting steriods?
- Prevent and Tx steroid induced osteoporosis – DEXA scan
- Screen fr increased risk of side effects of steriods – e.g DM, HTN, PMHx of peptic ulcer, osteoporosis, mental health history.
How often should patients with PMR be reviewed?
Ptx should be reviewed 1 wks after every dose change and every 3 months in first yr after diagnosis.
What is done at the review in PMR?
every 3 motnhs in first yr of diagnosis.
- Review symp of giant cell arthritis – and exclude
- Relapsing symp of PMR – proximal pain, fatigue and morning stiffness – if present increase dose of prednisolone to last dose that controlled symp.
- Assess side effects of steroids – weight gain, dyspepsia, muscle weakness, skin thinning and easy bruising.
o BP and glucose checks – affected by long term steroids.
When should someone with PMR be referred?
Refer if atypical features of PMR and no other cause of symp:
o < 60 yrs
o Red flags – weight loss, night pain, neuro features
o Don’t have core feature of PMR (bilateral shoulder/ pelvic pain or stiffness).
o features uncommon w/ PMR – normal inflammatory markers and or chronic onset of symp.
o Steroid required for more than 2 yrs.
o Repetitive flares of PMR
o Ptx is experiencing or is at high risk of adverse effects of steroids.
