Polymyalgia rheumatica (MSK)

Question 1

What is polymyalgia rheumatica?

Answer 1

Inflammatory rheumatological syndrome that manifests as pain and morning stiffness involving the neck, shoulder girdle, and/or pelvic girdle in individuals >50 years - relatively common

Question 2

What is the epidemiology of polymyalgia rheumatica? (2)

Answer 2

• F > M
• typically >50 years

Question 3

What are the causes of polymyalgia rheumatica? (2)

Answer 3

• genetic predisposition - specific allele of HLA-DR4
• associated with giant cell arteritis

Question 4

What is giant cell arteritis also known as?

Answer 4

Temporal arteritis

Question 5

What is the association between polymyalgia rheumatica and giant cell arteritis?

Answer 5

• 15-20% of patients with polymyalgia rheumatica have GCA
• 40-60% of GCA patients have polymyalgia rheumatica

Question 6

What are the features of giant cell arteritis (as a cause of polymyalgia rheumatica)? (5)

Answer 6

• unilateral vision loss
• headache
• jaw claudication
• scalp tenderness
• tender, palpable temporal artery

Question 7

What investigations are done for giant cell arteritis (as a cause of polymyalgia rheumatica)? (3)

Answer 7

• 1st line - raised ESR
• temporal artery biopsy should be done - may show skip lesions so if negative but still high suspicion, continue prednisolone and redo within 7 days
• fundoscopy for vision loss - swollen pale optic disc with blurred margins

Question 8

What would you see on fundoscopy in giant cell arteritis (as a cause of polymyalgia rheumatica)?

Answer 8

Swollen pale optic disc with blurred margins

Question 9

How do we treat giant cell arteritis (as a cause of polymyalgia rheumatica)?

Answer 9

• high dose steroids (IV methylprednisolone - given before biopsy done)
  
  • vision loss: IV methylprednisolone
  • no vision loss: high dose oral prednisolone
• urgent ophthalmology review (same day)
• if on steroids for long time - give bisphosphonates to protect bones

Question 10

Where does the pain in polymyalgia rheumatica come from?

Answer 10

Tissue around the joint gets inflamed - pain comes from structures around the joint (tendons, bursae) rather than joints themselves

Question 11

What are the clinical features of polymyalgia rheumatica? (6)

Answer 11

• shoulder/hip girdle stiffness and pain - bilateral morning stiffness and pain for >1h
• acute onset (starts unilateral arm tenderness –> bilateral within few weeks)
• worse at night/when walking
• systemic symptoms: low-grade fever, anorexia, weight loss, malaise, fatigue, depression
• symptoms of giant cell arteritis
• rapid response to steroids

Question 12

What symptom do we NOT get in polymyalgia rheumatica?

Answer 12

Weakness (unlike in polymyositis) - any weakness felt is due to muscle pain

Question 13

What are the risk factors for polymyalgia rheumatica? (3)

Answer 13

• age >50
• giant cell arteritis
• female

Question 14

What are the 1st-line investigations for polymyalgia rheumatica? (3 + 3)

Answer 14

• ESR
• CRP
• FBC
• (CK - normal; exclude myopathies)
• (RF - negative)
• (autoantibodies - negative)

Question 15

What is ESR/CRP like in polymyalgia rheumatica?

Answer 15

Elevated - ESR markedly raised

Question 16

What is ALP like in polymyalgia rheumatica?

Answer 16

ALP raised in 30%

Question 17

What might you see on ultrasound/MRI in polymyalgia rheumatica? (4)

Answer 17

• bursitis
• tenosynovitis
• synovitis
• joint effusions

Question 18

What are some differential diagnoses for polymyalgia rheumatica? (8)

Answer 18

• giant cell arteritis
• early rheumatoid arthritis
• hypothyroidism (muscle and joint pain, weakness in extremities, fatigue, delayed relaxation of deep tendon reflexes)
• fibromyalgia (pain more widespread, no stiffness)
• paraneoplastic syndrome (no response to low-dose prednisolone)
• polymyositis (symmetrical weakness, elevated muscle enzymes)
• overuse bursitis/tendonitis (no systemic symptoms)
• remitting seronegative symmetrical synovitis with pitting oedema

Question 19

What are the usual inclusion criteria for polymyalgia rheumatica? (5)

Answer 19

• age>50
• duration of symptoms >2 weeks (subacute)
• bilateral shoulder or pelvic girdle aching, or both
• morning stiffness lasting >45 minutes
• high ESR/CRP

Question 20

What is the 1st-line treatment for polymyalgia rheumatica?

Answer 20

Corticosteroids (prednisolone) - causes dramatic improvement within 1 week, then can start reducing dose slowly according to symptoms and ESR

Question 21

What do we give alongside steroid treatment for polymyalgia rheumatica?

Answer 21

Most need steroids for 2 years so give gastric and bone protection: calcium, vitamin D + bisphosphonates (alendronate)
(Corticosteroid-induced osteoporosis prophylaxis)

Question 22

What is the management plan for polymyalgia rheumatica?

Answer 22

• 1st line: corticosteroid (prednisolone) + consider NSAID (+Ca/vitD/bisphosphonate)
• 2nd line: methotrexate (steroid-sparing agent) - give folic acid to reduce risk of adverse effects e.g. oral ulcers
• 3rd line: tocilizumab - if contraindication or adverse effects from corticosteroids, beware liver injury

Question 23

What do we do if a patient with polymyalgia rheumatica is treatment-resistant or relapsed?

Answer 23

Increased dose of corticosteroid
(Consider methotrexate + folic acid)
(2nd-line: tocilizumab or leflunomide)

Question 24

What if patients with suspected polymyalgia rheumatica are not responsive to steroids?

Answer 24

Consider alternative diagnosis

Question 25

What are some complications of polymyalgia rheumatica? (5)

Answer 25

• temporal/giant cell arteritis
• CV, cerebrovascular and peripheral vascular complications
• relapse of disease
• corticosteroid-related complications (e.g. avascular necrosis of the femoral head)
• methotrexate complications