Polymyalgia Rheumatica

Question 1

What is polymyalgia rheumatica?

Answer 1

Inflammatory condition that causes pain and morning stiffness in shoulders, pelvic girdle and neck.

Question 2

What condition does polymyalgia rheumatica have a strong association with?

Answer 2

Giant cell arteritis

Question 3

Discuss the pathophysiology of polymyalgia rheumatica

Answer 3

Pathophysiology unknown. Thought that it is similar to giant cell arteritis as the two often occur together; however, no vasculitis has been found in polymyaliga rheumatica.

Question 4

State some risk factors for polymyalgia rheumatica

Answer 4

• >50yrs
• Giant cell arteritis
• Female

Question 5

Who does polymyalgia rheumatica commonly present in?

Answer 5

• >50yrs
• Female
• Caucasian

Question 6

State some symptoms of polymyalgia rheumatica

Answer 6

• New sudden onset o f proximal limb pain and stiffness (neck, shoulders, hips)
  
  • Pain worse with movement
  • Pain at night
• Systemic symptoms:
  
  • Weight loss
  • Fatigue
  • Low grade fever
  • Low mood
• Other features:
  
  • Carpel tunnel syndrome
  • Pitting oedema
  • Upper arm tenderness

Question 7

What might you find on clinical examination of someone with polymyalgia rheumatica?

Answer 7

• Decreased range of motion of shoulders, neck and hips
• Muscle strength is usually normal but may be limited by pain and/or stiffness
• Muscle tenderness

Question 8

Diagnosis of polymyalgia rheumatica is largely based on the history/clinical presentation and the response to steroids; true or false?

Answer 8

True

Question 9

NICE gives some core features that can be used to determine if a pt has polymyalgia rheumatica (PMR); state these 5 core features

Answer 9

Symptoms should be present for at least 2 weeks:

• Bilateral shoulder pain that may radiate to elbow
• Bilateral pelvic girdle pain
• Worse with movement
• Interferes with sleep
• Stiffness lasting for at least 45 minutes in morning

Question 10

State some differential diagnoses for someone presenting with joint pain & stiffness of neck, shoulder and pelvic girdle

Answer 10

• Osteoarthritis
• RA
• SLE
• Myositis (e.g from polymyositis or statins)
• Cervical spondylosis
• Adhesive capsulitis of both shoulders
• Hyper or hypo thyroidism
• Osteomalacia
• Fibromyalgia

*Its important to consider differential diagnoses as you may need to try and exclude these with the tests you do

Question 11

What investigations would you do if you suspect polymyalgia rheumatica, include:

• Investigations you do to support PMR diagnosis
• Investigations to rule out other causes

*Where appropriate, justify each/state result

Answer 11

Investigations to support PMR

• ESR
• CRP
• Plasma viscosity (usually do ESR instead)
• Consider temporal artery biospy is symptoms of GCA

Investigations to rule out other causes

• FBCs
• U&Es
• LFTS
• TFTs: hyper or hypothyroidism
• Calcium: decreased in osteomalacia
• Creatine kinase: raised in myositis
• Rheumatoid factor: rheumatoid arthritis
• Anti-CCP: rheumatoid arthritis
• ANA: SLE
• Urine Bence Jones protein: myeloma
• Serum protein electrophoresis: myeloma
• CXR: rule out lung & mediastinal abnormalities

Question 12

Normal inflammatory markers rules out polymyalgia rheumatica; true or false?

Answer 12

FALSE- normal inflammatory markers DO NOT rule out polymyalgia rheumatica. However, PMR with normal inflammatory markers is very uncommon.

Question 13

Discuss the management of polymyalgia rheumatica

Answer 13

• Steroids (prednisolone)
  
  • Initially 15mg per day
  • Re-assess after 1 week. If no reponse, suspect alternative diagnosis
  • Re-assess after 3-4 weeks. Expect 70% improvement in symptoms and inflammatory markersto return to normal.
  • Give 15mg dialy until symptoms are fully controlled then gradually reduce their dose over a period of months. If symptoms reoccur whilst reducing dose may need to increase dose or stay on dose longer before reducing again. Can take 1-2 yrs to wean a pt off steroids. Most pts on steroids for 18 months. If difficulty controllign symtpoms or steroids needed >2yrs refer to rheumatologist
• Methotrexate can be used in relapsing pts (it is steroid sparing)

Question 14

State some potential complications of polymyalgia rheumatica

Answer 14

• Chronic relapsing PMR
• ADRs associated with corticosteroids e.g. immunosupression leading to infections (due to long term corticosteroids), osteoporosis, hypertension
• ADRs associated with methotrexate e.g. oral ulcers, hepatotoxicity
• Decreased quality of life if symptoms not controlled