Polymyalgia Rheumatica Flashcards
Definition of PMR
A common inflammatory rheumatic disease of the middle aged and elderly
Characterised by pain and stiffness of the neck, proximal shoulder and hip girdle muscles
Constitutional signs of PMR
fever fatigue anorexia weight loss depression
What is relevance of steroids in PMR?
Clinical response to small doses off steroid can be dramatic and therefore diagnostic
Clinical features of PMR
Musculoskeletal symptoms bilateral / symmetrical
Muscle stiffness predominant
Stiffness severe after rest and on waking
Patients often unable to rise out of bed or dress
Muscle pain often diffuse, worse on movement
Pain at night common
Muscles tender
Muscle strength normal
Patients unable to raise arms above head
Mild arthritis of wrists, hands, knees and feet
Elevation of ESR and CRP
Normochromic, normocytic anaemia
What are the constitutional signs of PMR
WAFFeD: Weight loss Anorexia Fatigue Fever Depression
What is the British Society for Rheumatology Core inclusion diagnostic criteria?
Age >50 years
Duration >2 weeks
Bilateral shoulder or pelvic girdle pain or both
Morning stiffness duration >45mins
Acute phase response (ESR and CRP) elevated
What are the BSR exclusion criteria?
Active infection Active cancer Active GCA Other inflammatory diseases e.g. RA Polymyositis Drug induced myalgia e.g. statins Chronic pain syndromes e.g. fibromyalgia Adhesive capsulitis - frozen shoulder Endocrine disease e.g. hypothyroidism Neurological conditions e.g. Parkinson's
What are the investigations that need to be carried out?
Full blood count - normochromic normocytic anaemia C-reactive protein - raised --> CRP is a better marker of inflammation than ESR Erythrocyte sedimentation rate - raised Urea and electrolytes - normal Liver function tests ALT - normal Bone profile - alk phos raised Serum free light chains - no paraprotein Immunoglobulins - normal TSH/ Creatine kinase - normal ANA / anti-CCP antibodies - negative CXR - normal
What is the treatment of PMR?
Low dose prednisolone 15mg/ day
If there is no dramatic improvement in symptoms then review diagnosis
Be guided by clinical symptoms
Taper the corticosteroid dose gradually
What else is important to remember when prescribing treatment for PMR?
Co-prescribe bone protection - bisphosphonate, calcium and vitamin D
How soon should follow up be?
Follow up week 0, 1-3, 6 weeks
and then 3, 6, 9, 12 months in first year
What are some atypical features which suggest that PMR is not the diagnosis?
No improvement/no response to steroid Age <50-60 years Chronic onset >2 months Lack of shoulder involvement Lack of inflammatory stiffness Prominent systemic features Weight loss Night pain Neurological symptoms Features of other rheumatic disease Normal or extremely high acute-phase response
