Polymyalgia rheumatica

Question 1

define polymyalgia rheumatica

Answer 1

inflammatory condition of unknown cause-> characterised by severe bilateral pain and morning stiffness of shoulder, neck and pelvic girdle

POLYMYALGIA RHEUMATICA DOES NOT CAUSE WEAKNESS

Question 2

describe the typical presentation of polymyalgia rheumatica?

Answer 2

Bilateral pain and morning stiffness in shoulder and pelvic girdle region with no weakness. ESR and CRP elevated

Question 3

what condition of polymyalgia rheumatica associated with?

Answer 3

Temporal Arteritis– must ask if there are any vision changes or headaches

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 4

summarise the epidemiology of polymyalgia rheumatica?

Answer 4

Relatively common

Occurs in people aged > 50 yrs

Peak age of onset: 73 yrs

3 x more common in FEMALES

Question 5

what are the presenting signs and symptoms of polymyalgia rheumatica?

Answer 5

Tend to be relatively non-specific

Usual inclusion criteria for polymyalgia rheumatica:

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

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

1/3 patients also have constitutional symptoms such as low grade fever, depression, fatigue and anorexia

10% have carpal tunnel syndrome

Question 7

what are the appropriate investigaitons for polymyalgia rheumatica?

Answer 7

1) ESR/CRP - raised in polymyalgia rheumatica

2) ALP raised in 30%

3) FBC

Ultrasound

TFTS

Bone profile

Protein electrophoresis

Creatine kinase levels are normal– helps differentiate from myopathies

Others: urinary Bence Jones proteins, autoantibodies (e.g. anti-CCP antibodies)

Question 8

outline a management plan for polymyalgia rheumatica?

Answer 8

CORTICOSTEROIDS – prednisolone causes dramatic response within 1 week, then can start reducing dose slowly according to symptoms and ESR (+ calcium + vitD + bisphosphonate + NSAID)

• 15mg if pred which is then weaned down

Most need steroids for 2 years so give gastric and bone protection with PPI

Steroid-sparing agents (e.g. methotrexate) are 2ndline treatment+ folic acid

3rdline: Tocilizumab

Ongoing treatment: corticosteroid + Calcium + VitD + Bisphosphonate

Assistance from physiotherapy and occupational therapy

Monitor for adverse effects of steroids (e.g. osteoporosis, DM, Cataract, Avasc Necrosis)

Question 9

what are the possible complications of polymyalgia rheumatica?

Answer 9

Temporal arteritis

Relapse of disease

Complications of steroid use (e.g. fracture risk)

Question 10

summarise the prognosis of polymylagia rheumatica?

Answer 10

15% risk of getting temporal arteritis

Variable course and prognosis

Usually responds rapidly to steroid treatment

Relapse is common