Polymyalgia Rheumatica/PMR (1*)

Question 1

What is it?

Who does it usually present in?

What is it strongly associated with?

Answer 1

➊ Inflammatory condition, causing stiffness and pain in shoulders, neck, and pelvic girdle

➋ Caucasian women > 50 yrs

➌ Giant Cell Arteritis

Question 2

How long do symptoms have to be present for before making a dx?

How does it present?

What are its differentials?

How is it differentiated from Poly/dermatomyositis?

Answer 2

➊ > 2 wks

➋ * Bilateral shoulder and pelvic girdle pain that’s worse with movement
* Morning stiffness

➌ * OA, RA, SLE, Cervical spondylosis
* Thyroid disease
* Poly/dermatomyositis

➍ * Myositis presents with bilateral proximal muscle weakness, and is painless
* PMR present with pain and there isn’t any muscle weakness

N.B. Always have myopathy as a differential e.g. polymyositis, statin-induced myopathy. These will have a raised CK.

Question 3

Investigations:
What is the diagnosis based on?

What are the most indicate markers to check?

What other investigations need to be done?

Answer 3

➊ Clinical presentation and response to steroids

➋ CRP and ESR - ESR will be very high

➌ • FBC, U&E, TSH
• LFT (ALP), Bone profile - for metabolic bone disease
• CK - for myositis
• RF and anti-CCP - for RA
• ANA - for SLE

Question 4

Management:
How is it managed?
→ How long can the weaning process take?

What should all these pts have on them?

What should these pts all be given alongside the steroids?

Answer 4

➊ * Start on Prednisolone 15mg PO
‣ Should be a major improvement after 3-4 weeks - If not, PMR is unlikely, and an alternative dx is needed, so stop steroid
* After good response, start on Reducing Regime
‣ Stay on 15mg until full symptomatic control
* If symptoms recur while on reducing regime, you may need to increase dose or stay on dose longer before reducing again
→ 1-2 yrs

➋ Blue Steroid Card as they’ll be on it long-term

➌ Bisphosphonates for bone protection

N.B. Prednisolone has a much higher glucocorticoid (anti-inflammatory) affect than Hydrocortisione, therefore making it a better drug for long-term disease suppresion. Also, Hydrocortisone has a higher relative mineralocorticoid (fluid retention) affect, therefore putting pts at risk if used as a long-term agent.