Polymyalgia Rheumatica

Question 1

Define:

Answer 1

• An inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.
o NOTE: polymyalgia rheumatica does NOT cause weakness

Question 2

Aetiology/risk factors;

Answer 2

• UNKNOWN pathogenesis
• Genetic and environmental factors
• Associations – not a true vasculitis but has same demographic characteristics as GCA
o Temporal Arteritis
 40-50% of people with temporal arteritis have polymyalgia rheumatica
 15% of people with polymyalgia rheumatica will go on to develop temporal arteritis
 Both conditions respond to corticosteroids

Question 3

Epidemiology:

Answer 3

• Relatively common
• Occurs in people aged > 50 yrs
• Peak age of onset: 73 yrs
• 3 x more common in FEMALES

Question 4

Inclusion criteria:

Answer 4

o Age > 50 yrs
o Duration of symptoms > 2 weeks (subacute)
o Bilateral shoulder or pelvic girdle aching, or both
o Morning stiffness lasting > 45 mins
o High ESR/CRP

Question 5

Signs/symptoms:

Answer 5

• The characteristic clinical picture of polymyalgia rheumatica: bilateral shoulder pain and stiffness of acute or subacute onset with bilateral arm tenderness
• NO WEAKNESS
• Symptoms are worst when walking
• Morning stiffness may be so bad that they find it difficult to get out of bed, or raise their arms enough to brush their hair
• May be flu-like symptoms at onset – may also get weight loss, fatigue
• 10% have carpal tunnel syndrome

Question 6

Investigations:

Answer 6

• ESR/CRP - raised in polymyalgia rheumatica
• ALP raised in 30%
• FBC
• U&Es
• LFTs
• Bone profile
• Protein electrophoresis
• TFTs
• Creatine kinase levels are normal – helps differentiate from myopathies
• Others: urinary Bence Jones proteins, autoantibodies (e.g. anti-CCP antibodies)

Question 7

Management:

Answer 7

• CORTICOSTEROIDS – prednisolone causes dramatic response within 1 week, then can start reducing dose slowly according to symptoms and ESR
• Most need steroids for 2 years so give gastric and bone protection
• Steroid-sparing agents (e.g. methotrexate) are rarely used – trials have been inconsistent
• Assistance from physiotherapy and occupational therapy
• Monitor for adverse effects of steroids (e.g. osteoporosis)

Question 8

Complications:

Answer 8

• Temporal arteritis
• Relapse of disease
• Complications of steroid use (e.g. fracture risk)

Question 9

Prognosis:

Answer 9

• 15% risk of getting temporal arteritis
• Variable course and prognosis
• Usually responds rapidly to steroid treatment
• Relapse is common