Polymyalgia rheumatica Flashcards
What medication rapid response to in PMR
Corticosteroids
Where does PMR classically cause pain
Stiffness in shoulder and pelvic girdles
How differentiate between myositis and PMR
Reduced muscle strength in myositis
What condition od 15% of PMR patients develop
Giant cell arteritis
Who does PMR present
> 50 years
70-80 most common
3 x more in women
Cause of PMR
Environmental factors and genetics
HLA-DRB104 and -DRB101 alleles have been observed, which may increase susceptibility to developing PMR.
Onset of PMR
Subacute - 2-6 weeks
Shoulder features in PMR
Tenderness, bursiitis, ROM - localise to neck muscles tenderness
Systemic sympotms in PMR
Low grade fever, fatigue, anorexia, weight loss, depression
Features of PMR
Shoulder and pelvic girdle pain
Rapid response to steroids
Systemic symptoms - low grade fever, fatigue, anorexia, weight loss depression
Peripheral oligarticular arthritis - wrist, knees, MCPs
What would suggest presentation is not PMR
<50 years
Normal inflammatory markers
What red flags need to screen for in PMR
Paraneoplastic syndrome -
-Resp, urinal haema nd GI systems
What can delayed presentation of polymyalgia rheumatica cause
Muscle wasting
Referral guide for PMR to secondary care
<60 years
Red flags of serious pathology incl weight loss, night pain or neuro
Dont have core features eg bilateral shoulder/pelvic girdle pain #>45 mins morning stiffness
Unusual features PMR - normal or v high inflam markers
Chronic onset of symptoms
Limited repsonse to steroids
Why can RA be confused for PMR
Initial phase can present similarly to PMR - synovitis or clinical features of RA -. refer for RA
Signs of GCA
Headache, jaw claduciation, visual disturbance
PMR steroid trematne t
Prednisolone 15mg OD
Weaned off gradually dose adjust every 4-8 weeks
Review one week after each adjustment
If frequent relapses or higher risk from adverse effect of steroids - DMARD - methotrexate
Toclixumab - 3rd line
Risks of corticosteroids
Osteoporosis
Increased risk of infection
#T2DM
HPTN
Cataract
Glaucoma
#Skin changes - thinning, bruising
Complications of GCA
Permanent vision loss
Factors increasing risk of relapse
Female sex
High inflam markers
Peripheral arthritis
Course of steroids prognosis
Paitents will relapse at some point
On steroids for 2-3 years
WHat is GCA
Vasculitis of medium and large vessels occuring i over 50s
Why si prompt treatment in GCA vital
Prevent permanent vision loss
GCA features
Rapid onset <1 months
Headache
Jae claudication
Vision eg amourosis fugax, diplopia
Tender, palpable temporal artery
PMR symptoms
Lethargy, depression, low grade fever, night sweats
wHAT IS CAUSE OF MAJORITY OF OCULAR COMPS IN gca
anterior ischemic optic neuropathy - Occlusion of posterior ciliary artery ->ISCHAEMIA OF OPTIC NERVE HEAD
Fundoscopy of anterior ischemic optic neuropathy
Swollen pale disc + blurred margins
Diagnosis of GCA criteria
3 or more of:
>50 years
New onset of headache
Temporal artery abnormality - tenderness, thuckened or reduced pulsation
ESR>50
Abnormal artery biopsy
Changes consistent with GCA on biopsy
Investigations for GCA
ESR>50
CRP
Temporal artery biopsy - skip lesions
CK and EMG - normal
Investigations for low clinical probability of GCA
Tmeporal axillary artery US - if postiive biopsy to diangosie within 14 dyas of steroids
Medium vs high clinical probability of temporal arteritis
US prior to biopsy
High - US is sifficent alone to diagnose
Central retinal artery occlusion on fundoscopy
Cherry red spot with retinal awhiteneing
When should high dose steroids be used GCA
As soon as diagnosis suspected - before artery biopsy
What steroids are used visual loss vs none
No visual loss - oral pred
Evolving visual loss - IV methylprednisolone prior to oral pred
Should be a dramatic response
What need to give along steroids in GCA
Bisphosphonates due to long course of steroids
Low dose aspirin
Complications of GCA
Visual loss - anterior ischaemic optic neuropathy
Ocular comps eg retinal artery occlusion, diplopia, ptosis
Stroke
Aortic aneurysm and dissection
Large cessel involvement - axillary, vertebral, SC, cranial -> limb claduaication, ishcaemia, vertebrobasilar insufficiency
PMR
Systemic symptoms
Long term steroids use risks
Osteoporosis
Diabteets
HPTN
Increased infection susceptibility
