Polymyalgia Rheumatica Flashcards
What is polymyalgia rheumatica?
A chronic, systemic rheumatic inflammatory condition that causes pain and stiffness in the shoulder, pelvic girdle and neck.
It is associated with synovitis of proximal large joints, tenosynovitis and bursitis.
What conditions is polymyalgia rheumatica associated with?
Giant cell arteritis
Carpel tunnel syndrome
Peripheral oedema
What are the risk factors for polymyalgia rheumatica?
Older white patients - above 50yrs, peak 70-80yrs
Female sex - over 65%
Infection - cyclic fluctuations and peaks in incidence over winter - associated with chlamydia pneumonia, mycoplasma etc.
Northern Eastern Ancestory
Family history
Previous giant cell arteritis.
How does polymyalgia rheumatica present?
Rapid onset over days to weeks
Present for two weeks before diagnosis considered
Pain and stiffness of the shoulder, pelvic girdle and neck.
Worse in the morning, after rest, interfere with sleep, takes at least 45mins to ease in the morning, improve with activity.
Muscle tenderness
Systemic - weight loss, fatigue and low-grade fever.
What investigations should be done for polymyalgia rheumatica before steroids are given?
Bloods: Inflammatory screen (ESR, CRP, Plasma viscocity), FBC (normocytic anaemia or thrombocytosis in ongoing inflammation), U&Es, LFTs, calcium, Serum protein electrophoresis, TSH, Creatine kinase, RA,
Imaging: US and MRI and FDU PET
Other: Urine dipstick
If PMR is the most likely diagnosis what test should be done to confirm this?
Prescribe a trial of oral prednisolone 15mg daily and arrange 1w follow-up to assess clinical response.
Patient should report improvement within 1w, should have normalisation of inflammatory markers in 4 weeks.
A positive response is indicative that PR is the most likely diagnosis.
When should people with Polymyalgia rheumatica as a differential diagnosis be referred to a specialist?
Are younger than 60yrs of age
Red flags - weight loss, night pain, neurological features
Do NOT have bilateral shoulder or pelvic girdle aching, stiffness for 45mins after rest
If inflammatory markers are normal
Chronic onset of symptoms.
What are the signs/symptoms of giant cell arteritis?
Abrupt onset headache (usually temporal)
Temporal/scalp tenderness
Visual disturbance - diplopia
Jaw or tongue claudication
Change in temporal artery pulse
Upper cranial nerve palsies
Limb claudication or evidence of large vessel disease.
What is the initial treatment for polymyalgia rheumatica?
15mg prednisolone daily
Follow up after 1week
Dramatic improvement of at least 70%
What is the long term treatment of polymyalgia rheumatica?
15mg prednisolone daily until symptoms are fully controlled
12.5mg for 3 weeks
10mg for 4-6weeks
Reducing by 1mg every 4-8weeks
What guidance is given for management of patients on long term steroids.
Dont STOP
D - dependence - occurs after 3w of treatment abrupt stop can cause adrenal crisis
S - sick day rules - dose may need increasing
T - treatment card - to alter others they are steroid dependent
O - osteoporosis prevention (bisphosphonates, calcium and vitamin D)
P - PPIs for gastro-protection.
What is the prognosis for polymyalgia rheumatic like?
Response to systemic corticosteroids is often rapid and dramatic
Symptoms tend to resolve within 24-72houes
50% of patient will not respond within 4weeks, often need 9-12months of treatment - but can be lifelong.
Relapse is common.
What is the aetiology of polymyalgia rheumatica?
Immune mediated inflammatory disorder
Genetic predisposition combined with neurohormonal regulation as age may trigger
Tends to affect the peri-articular structures such as tendons, bursa and synovium.
What are the typical findings of polymyalgia rheumatic on clinical examination?
Bilateral proximal muscles - diffusely tender to touch - may indicate bursitis
Active and passive range of motion is limited by pain
Muscle strength is normal or limited by pain in the proximal muscles
Scalp may be tender to touch - GCA
Examination of the temporal artery - thickened with diminished or lack of palpable pulse
Neurological examination is usually normal.
Struggle to lift arms above head and struggle to stand up from sitting down.
How does polymyalgia rheumatic appear on imaging?
US - commonly shows joint effusion, synovitis, bursitis
MRI - synovitis and bursitis
FDU PET - inc uptake in areas of inflammation
