Polymyalgia rheumatica profoma

Question 1

What is polymyalgia rheumatica?

Answer 1

inflammatory condition that causes pain & stiffness in the neck, shoulders & pelvic girdle.

Associated w/ Giant cell arteritis- red flag!

Question 2

Epidemiology of polymyalgia rheumatica?

Answer 2

Must be ≥ 50 years old- average age is 70.

More common in Caucasians & women

Question 3

Pathophysiology of polymyalgia rheumatica?

Answer 3

• Unclear
• Inflammatory role of IL-6.
• Immune imbalance - PMR patients have a decline of immunosuppressive T-regulatory lymphocytes & increase in pro-inflammatory T-helper cells.
• Associated w/ HLA-DR4

Question 4

Presentation of polymyalgia rheumatica?

Answer 4

• Symmetrical pain & stiffness in shoulder & pelvic girdle.
• Disturbs sleep & morning stiffness present.
• Systemic symptoms: Weight loss, fatigue, low grade fever, low mood.
• Often w/out synovitis - associated w/ redness, warmth, swelling & pain on movement.
• No loss of function, weakness or wasting - movement isssues are not functional issues but due to pain.

ALWAYS rule out giant cell arteritis- ask about those symptoms

Question 5

Investigations for polymyalgia rheumatica: blood tests

Answer 5

• ESR - high (can rarely present w/ normal ESR)
• FBC - normocytic, normochromic anaemia
• CRP - can be high
• LFTs - can be abnormal
• Creatinine kinase - normal (unlike polymyositis).
• Anti-CCP - rules out RA
• ANA - rules out SLE

Question 6

Investigation for polymyalgia rheumatica: imaging & biopsy

Answer 6

Imaging:
- Ultrasound of temporal arteries - to exclude GCA.
- PET scan - the glucose accumulates around the shoulders, sternoclavicular & hip joints.

Biopsy:
Temporal artery biopsy - to exclude GCA!!

DEXA Scan:
- long term used steroids can lead to bone density loss, osteoporosis & fractures
- therefore assess risk of fracture via DEXA

Question 7

Management for polymalgia rheumatica

Answer 7

1. Glucocorticoids/ steroids e.g. Prednisolone- 10-15 mg
   - Poor response to steroids should put diagnosis in doubt.
2. Bone-protective drugs e.g. bisphosphonates & Vit D.
3. Monitored regularly - dose should be progressively reduced, guided by symptoms & ESR.
4. Recurrent flares- methotrexate or azathioprine.

Question 8

Prognosis for polymalgia rheumatica

Answer 8

• Overall prognosis for PMR is good
• Relapses or symptom exacerbations common
• Most patients should not be receiving treatment after 2 years