Polymyalgia Rheumatica

Question 1

What is polymyalgia rheumatica (PMR)?

Answer 1

It is defined as an immune-mediated inflammatory disorder of the proximal muscles

Question 2

Which three regions of the body tend to be affected by polymyalgia rheumatica?

Answer 2

Neck

Shoulder

Pelvic Girdle

Question 3

What five risk factors are associated with polymyalgia rheumatica?

Answer 3

Older Age > 50 Years Old

Female Gender

White Race

Family History

Giant Cell Arteritis

Question 4

Are the clincial features of polymyalgia rheumatic unilateral or bilateral?

Answer 4

Bilateral

Question 5

When do the clinical features of polymyalgia tend to present?

Answer 5

Acutely - over a period of 2 weeks

Question 6

What are the nine clincial features of polymyalgia rheumatica?

Answer 6

Fatigue

Low Grade Fever

Proximal Muscle Aches

Proximal Muscle Morning Stiffness

Reduced Proximal Muscle Movement

Polyarthralgia

Depression

Weight Loss

Night Sweats

Question 7

Which clincial feature is not associated with polymyalgia rheumatica?

Answer 7

Proximal Muscle Weakness

Question 8

What four investigations are used to diagnose polymyalgia rheumatica?

Answer 8

Blood Tests

Ultrasound Scans

MRI Scans

Fluorodeoxyglucose F-18 Positron Emission Tomography (FDU PET)

Question 9

Which three blood tests indicate polymyalgia rheumatica?

Answer 9

Increased ESR Levels > 40mm/hr

Increased CRP Levels

Normal Creatinine Kinase

Question 10

What are the three features of polymyalgia rheumatica on ultrasound scans?

Answer 10

Joint Effusion

Synovitis

Bursitis

Question 11

What are the two features of polymyalgia rheumatica on MRI scans?

Answer 11

Synovitis

Bursitis

Question 12

What is the feature of polymyalgia rheumatica on FDU PET scans?

Answer 12

There is increased uptake within the bursa/synovium of the shoulders, ischial tuberosity and greater trochanters

Question 13

What are the four diagnostic criteria of polymyalgia rheumatica?

Answer 13

Age > 50 Years Old

Morning Proximal Muscle Stiffness/Pain

Increased ESR/CRP Levels

Steroid Therapy Response

Question 14

What is the gold standard management option of polymyalgia rheumatica?

Answer 14

Glucocorticoids

Question 15

Name a glucocorticoid steroid used to manage polymyalgia rheumatica

Answer 15

Prednisolone

Question 16

Describe the glucocorticoid regime used to manage polymyalgia rheumatica

Answer 16

It involves initial administration of 15mg of prednisolone per day, which is then tapered over a period of weeks to months as clinical features resolve and inflammatory markers improve

Question 17

Why is a glucocorticoid tapering regime important in polymyalgia rheumatica?

Answer 17

A rapid withdrawal of steroids after long term use can result in Addisonian crisis

Question 18

What is the glucocorticoid regime used in polymyalgia rheumatica?

Answer 18

The prednisolone 15mg once daily dose is administered until clinical features are fully controlled – usually 3 weeks

The prednisolone dose is then reduced to 12.5mg once daily for 3 weeks

The prednisolone dose is then reduced to 10mg once daily for 4 – 6 weeks

The prednisolone dose is then reduced by 1mg every 4 – 8 weeks until treatment is stopped

Question 19

What are the three main side effects of chronic glucocorticoid steroid therapy?

Answer 19

Osteoporosis

Gastro-Oesophageal Reflux Disease

Hyperglycaemia

Question 20

What should immediately be administered with glucocorticoid in order to prevent osteoporosis side effects?

Answer 20

Bisphosphonates

Calcium Supplements

Vitamin D Supplements

Question 21

What should immediately be administered with glucocorticoid in order to prevent GORD side effects?

Answer 21

Proton Pump Inhibitors (PPIs)

Question 22

What is the most appropriate management step when polymyalgia rheumatica doesn’t respond to prednisolone after one week?

Answer 22

There should be consideration of an alternative diagnosis – therefore we conduct specialist referral and stop steroid administration