Polymyalgia Rheumatica and GCA

Question 1

What is PR?

Answer 1

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

Large vessel vasculitis

Strong association with GCA

Question 2

What are the risk factors for PR?

Answer 2

Age >50
Female
Caucasian ethnicity

Question 3

What are the symptoms of PR?

Answer 3

Sudden/insidious onset
Severe pain/stiffness in neck, shoulders, hips and lumbar spine

Worse in the morning lasting >30mins
Worse on movement
Often bilateral
Interferes with sleep

Systemic features

• tiredness
• fever
• weightloss

Can also get

• pitting oedema
• carpal tunnel syndrome
• upper arm tenderness

Question 4

What are the signs of PR?

Answer 4

Muscles tender to palpate esp in upper arm

Muscle wasting

Muscle weakness in upper and lower proximal regions

Question 5

How is it diagnosed?

Answer 5

Symptoms must be present for >2wks
Symptoms of bilateral shoulder or pelvic girdle pain
Morning stiffness

Question 6

What are differentials?

Answer 6

SLE
OA
RA
Myositis
Osteomalacia

Question 7

What investigations are needed?

Answer 7

Lots to rule out other conditions

Bloods

• FBC
• U&Es
• LFTs
• Calcium- hyperparathyroidism (high) or osteomalacia (low)
• TSH
• CK- for myositis
• Rheumatoid factor- RA
• ANA- for SLE
• Anti-CCO- for myeloma

Urine dip

CXR for lung and mediastinal abnormalities

Question 8

What is the management?

Answer 8

Initially 15mg prednisolone/day

Assess 1wk later
-if no response=unlikely PR so stop steroids

If improvement reassess after 3/4wks

• inflam markers should return to normal and 70% improvement in symptoms
• start to reduce dose

If symptoms reappear then increase dose or stay on the same dose for longer before reducing

Question 9

What is GCA?

Answer 9

Systemic vasculitis of medium and large arteries

Typically presents with symptoms affecting temporal arteries

Question 10

What are the symptoms of GCA?

Answer 10

Severe unilateral headache
Scalp tenderness- when brushing hair
Jaw claudication
Blurred/double vision
Irreversible painless sightloss can happen quickly

Systemic features

• fever
• fatigue
• weight loss
• muscle aches

Question 11

What are the signs of GCA?

Answer 11

Tenderness/swelling of one/both temporal arteries
Overlying scalp inflammation
Reduced/absent temporal pulse
Poor visual acuity
Swollen optic disc on fundoscopy

Question 12

How is GCA diagnosed?

Answer 12

Based on

• Clinical presentation
• raised ESR
• Temporal artery biopsy findings- multinucleated giant cells found

Question 13

What other investigations are needed for GCA?

Answer 13

FBC- normocytic anaemia and thrombocytosis
LFTs- raised ALP
CRP- raised
Duplex USS of temporal artery shows hypoechoic halo sign

Question 14

What is the management of GCA?

Answer 14

Start on steroids immediately before confirming diagnosis

40-60mg prednisolone/day

• 60mg if jaw claudication or visual symptoms
• 40mg- if none
• review in 48hrs

Response to treatment is normally rapid

Gradually decrease over time

Aspirin 75mg daily decreases visual loss and strokes

Question 15

What are measures that are needed for long term steroid use?

Answer 15

Don’t STOP

Don’t-
-become steroid dependent after 3 weeks so do not suddenly stop- must taper dose down

S-sick day rules
-increase steroid dose if unwell

T- treatment card
-to alert others they are steroid dependent

Osteoporosis prevention
-need prophylactic bisphosphonates, calcium and VitD

PPI
-for gastric protection