Polymyalgia Rheumatica Flashcards
What is poly myalgia rheumatica?
Inflammatory condition causing pain and stiffness (NOT WEAKNESS) in:
-shoulder girdle
-pelvic girdle
-neck
What other condition is there a very strong association with Poly myalgia rheumatica?
Giant cell arteritis
What is the diagnostic criteria for polymyalgia rheumatica?
Age > 50
Pain bilaterally in shoulders or pelvis or both for >2weeks
Morning Stiffness >45mins
Evidence of an acute phase response
What scenarios need to be ruled out before a diagnosis of polymyalgia rheumatica is made?
Active infection
Active cancer
Active giant cell arteritis
What are some questions that can be asked to rule out active giant cell arteritis when working up a polymyalgia rheumatica diagnosis?
Exam findings?
Any headaches?
Double vision/visual disturbance
Jaw pain?
Pain in the limbs when walking (limb claudication)
Upper cranial nerve palsy’s examinable
Altered temporal artery pulse examinable
What are some differentials for a patient with pain and stiffness in shoulders bilaterally and pelvis, low grade fever?
Polymyalgia rheumatica
Osteoarthritis
Rheumatoid arthritis
SLE
Statin induce myopathy
Myositis
Adhesive capsulitis
Osteomalacia
Hyper or Hypoparathyroidism
Fibromyalgia
Lymphoma
Myeloma
What are some investigations that should be done when trying to investigate someone who might have polymyalgia rheumatica?
FBC
U+Es (if it’s a lupus may be causing nephritis)
LFTs
Calcium (hyperparathyroidism, cancer and osteomalacia)
TSH (thyroid function)
Creatine kinase (myositis)
Rheumatoid factor (Rhuematoid arthritis)
Bone profile (osteomalacia)
Antibodies
What antibodies do you want to check for and why when trying to diagnose polymyalgia rheumatica?
ANA = Lupus
Anti CCP = rheumatoid arthritis
Urine bence jones proteins = myeloma
How is polymyalgia rheumatica treated?
Start on Prednisolone 15mg daily oral for 3 weeks
SHOULD SIGNIFICANTLY IMPROVE IN 3 DAYS-7DAYS IF DONT CONSIDER OTHER DIAGNOSIS
What is the regime for corticosteroids/prednisolone for a patient with polymyalgia rheumatica?
Pred daily oral 15mg for 3 weeks
Then 12.5mg for 3weeks
10mg for 4-6 weeks
Then reduce dose by 1mg every month (4weeks) until completely weened off
What do you do if you’re treating a patient with prednisolone who has polymyalgia rheumatica and they relapse ?
Return to dose that didn’t have relapse
If relapse again treat with methotrexate
What medication do you use if the patient has relapsed twice when being treated with prednisolone?
Methotrexate
Why cant you suddenly stop giving prednisolone?
Can lead to an adrenal crisis since the exogenous source of corticosteroids inhibits the production of Corticotropin releasing hormone (CRH) from the hypothalamus and so ACTH (Adrenocorticotropic hormone) so the body cant produce glucocorticoids like cortisol
Which part of the adrenal glands is most atrophied when giving long term corticosteroids?
Zona fasiculata
(Glucocorticoids)
How does an adrenal crisis present following sudden cessation of long term corticosteroids and why?
Unable to produce cortisol:
-hypoglycaemia
-hypotension (shock)
-electrolyte imbalance (Mineralocorticoids also reduced)
-inflammatory dysregulation
Confusion
Nausea + Vomitting
What is the function of cortisol?
Gluconeogensis
Maintains vascular tone (vasoconstriction)
Dampening systemic inflammation
What medications should be prescribed with long term corticosteroids like prednisolone and why?
Bisphosphonates, calcium and vitamin D (causes osteoporosis)
Proton pump inhibitors like omeprazole ( they inhibit prostaglandin synthesis so gastric mucosal blood flow impaired and impaired regeneration of gastric epithelium)
How should dose of steroid be adjusted for a patient on long term corticosteroids if they become sick?
Double the dose
What investigation is important giant cell arteritis?
What if it’s negative?
Biopsy of temporal artery
Even if its negative dont exclude GCA since could be skip lesions if clinical suspicion is high
How do you treat Giant cell arteritis?
40-60mg prednisolone if no jaw claudication or visual disturbance
500 - 1000mg (IV) methylprednisolone if jaw claudication or visual disturbance
Daily
What medications would you give alongside long term corticosteroids for Giant Cell arteritis?
Aspirin 75mg (decrease risk of strokes and vision loss)
PPIs
Bisphosphonates, Calcium and vitamin D
