polymyalgia rheumatica Flashcards
define polymyalgia rheumatica
inflammatory rheumatological syndrome
peripheral musculoskeletal involvement may be present
occurs either as an isolated condition or with GCA (giant cell arteritis)
inflammation prodominant in the shoulder or hip
get bursitis - fluid in bursa (trochanteric or subarcomial)
epidemiology of PMR
common in elderly
>50yrs
female
aetiology of PMR
unknown
seasonal variation suggest infectious agent - but not been established
genetic - becasue of difference in ethnicity and familial cases
association with HLA-DRB1*04 and HLA-DRB*01 alleles with genetic polymorphisms for ICAM-1, TNF-a, and IL-1 receptor antagonist – may influence suseptibility
potential role of hormones because of adrenal gland hypofunction in untreated patients
pathology of PMR
unclear
similar to GCA suspected
IL-6
in situ macrophage-derived cytokine mRNA profiles
imbalance in immunological regulation
regulatory role for B cells in the pathogenesis
RF for PMR
GCA
>50yrs
presenting symptoms of PMR
subacute onset <2wks of bilateral aching, tenderness and morning stiffness in shoulders, hips, and proximal limb muscles
restricted shoulder and hip movements
+- fatigue
fever
weight loss
anorexia
depression
may be associated mild tenosynovitis and carpal tunnel syndrome
NOT weak
investigations for PMR
high CRP/ESR typically >40
AlkP is high in 30%
CK normal - distinguish from myositis/myopathies
ddx for PMR
recent onset RA
polymyositis
hypothyroidism
primary muscle disease
occult malignancy or infection
OA - especially cervical spndylosis, shoulder OA
neck lesions
bilateral subacromial impingement
spinal stenosis
treatment of PMR
oral prednisolone 15mg/d
expect dramatic response within 1 wk
reduce dose slowly by 1mg/mo according to symptoms and ESR
investigate ‘flares’ in withdrawal - could be due to a different condition
most need steroids for >2yrs - give bone protection
methotrexate under specialist supervision for pts at risk of prolapse/prolongued therapy
inform to seek urgent review if symptoms of GCA develop
complications of PMR
GCA
chronic relapsing PMR
secondary to corticosteroids:
- increased risk of infection
- HTN
- muscle weakness
- cataract development
- glaucoma
- skin changes
- osteoporosis
- T2DM
secondary to methotrexate:
- myelosuppression
- oral ulcers
- hepatoxicity
- interstitial lung disease
PMR related vascular events
prognosis of PMR
good
relapse common
treatment takes 2-3yrs
chronic relapsing course need longer treatment
if have GCA - prognosis is directly related to that
increased risk of relapse/prolongued therapy has shown association with female, high ESR >40 and peripheral arthritis
