Polymyalgia Rheumatica Flashcards
What is Polymyalgia Rheumatica (PMR)?
A clinical syndrome characterized by pain and stiffness of the shoulder, hip girdles, and neck
Patients may use the term stiffness and pain interchangeably. Primarily impacts the elderly, associated with morning stiffness and elevated inflammatory markers.
Who is primarily affected by Polymyalgia Rheumatica?
Incidence increases with age, average age of onset ~70 years, rare in people <50 years of age, peak incidence is between ages 70 and 80
PMR is also associated with Giant Cell Arteritis (GCA).
What are common symptoms of Polymyalgia Rheumatica?
- new sudden onset proximal limb pain and stiffness
- difficulty rising from a chair or combing hair
- night time pain
- systemic symptoms (fatigue, weight loss, low-grade fever)
Symptoms typically involve the neck, shoulders, and hips.
What physical exam findings are associated with Polymyalgia Rheumatica?
- decreased range of motion in shoulders and neck
- muscle tenderness
Range of motion may be limited by pain and/or stiffness.
How is Polymyalgia Rheumatica diagnosed?
Typical history and exam supported by raised inflammatory markers - investigations before initiating steroids!
Check either ESR or PV as well as CRP. Consider temporal artery biopsy if symptoms of GCA.
What is the treatment for Polymyalgia Rheumatica?
Expect a dramatic response within 5 days of starting prednisolone, typically 15 mg daily - follow up after 1 week
Treatment is tapered very slowly, as rapid taper is associated with symptom relapse. Methotrexate can be steroid-sparing in relapsing patients.
True or False: PMR with normal inflammatory markers is common.
False
PMR with normal inflammatory markers is very uncommon.
What should be reconsidered if there is not a dramatic and rapid response to steroids?
Reconsider the diagnosis
Adjust steroids according to symptoms, not ESR/CRP.
How long do most patients require treatment with prednisolone for Polymyalgia Rheumatica?
Most patients require 18 months of treatment
Treatment duration may vary based on individual response.
Fill in the blank: Certain _______ can have polymyalgia at presentation.
[cancers]
This highlights the need for differential diagnosis in patients presenting with polymyalgic symptoms.
What other condition can present with initial polymyalgic symptoms?
Rheumatoid arthritis
This suggests overlapping symptoms which can complicate diagnosis.
what are the characteristic features of pain and stiffness
- Worse in the morning
- Worse after rest or inactivity
- Interfere with sleep
- Take at least 45 minutes to ease in the morning
- Somewhat improve with activity
give some examples of investigations which might be carried out prior to diagnosing PMR
- FBC, U&Es, LFTs, calcium, CK
- ANA for SLE
- anti-CCP for RA
- urine bence jones protein for myeloma
- CXR for lung and mediastinal abnormalities e.g. lung cancer or lymphoma
what is the reducing regime of prednisolone
- 15mg until the symptoms are fully controlled, then
- 12.5mg for 3 weeks, then
- 10mg for 4-6 weeks, then
- Reducing by 1mg every 4-8 weeks
what are additional managements for patients on long term steroids
Don’t STOP
- Don’t – steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
- S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
- T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
- O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
- P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)
