Rheumatology Flashcards
Polymyalgia rheumatica
* Definition
* Etiology
- PMR is an inflammatory condition that causes pain and stiffness in the proximal extremities
Epidemiology
* Typically in adults over 50 years old
* 2:1 female:male ratio
PMR
Comorbidities and prognosis
- 50% relapse rate
- Associated conditions: Giant cell arteritis (GCA)
-15% develop GCA
-50% of patients with GCA may have PMR on presentation
PMR
Signs + Symptoms
- Constitutional symptoms (fever, weight loss, malaise)
- Morning stiffness in symmetrical pattern of proximal muscles (neck, shoulder, hips, and thighs)
- Functional impact: difficulty dressing, rising from seated positions, or lifting arms above shoulders
- 15-30% May have distal MSK symptoms (eg: arthritis, swelling, edema, carpal tunnel syndrome)
- Physical exam: tender muscles but no weakness/atrophy
PMR
Diagnosis
* inclusion and exclusion
Inclusion criteria
* Age >50
* Duration > 2 weeks
* Abrupt onset
* Morning stiffness >45 mins
* Bilateral shoulder +/- pelvic girdle pain
* Elevated ESR/CRP
Exclusion criteria
* Malignancy
* Infection
* GCA
* Inflammatory conditions (RA, SLE, myopathies)
* Non-inflammatory condition (fibromyalgia, OA)
* Drug induced (statins)
PMR
Investigations
- Hb (low)
- Platelets (elevated)
- ESR/CRP (elevated)
- CK is normal
- Consider LFTs, calcium, ALP, SPEP, TSH, CK, RF, ANA, CXR ?anti-CCP
- Do a baseline BMD
PMR
Management
- Prednisone: 15-20mg to be tapered over 2 years while monitoring ESR
- Elevated ESR or CRP is not an indication to remain on steroid if asymptomatic.
- Don’t forget stomach and bone protection while on steroids
- Monitor every 3 months: serial ESR, CBC, lytes, glucose
- Expect rapid symptoms relief and ESR to normalize within 4 weeks
- Continue to monitor for symptoms, signs of giant cell arteritis and steroid side-effects
- *If no GCA, urgent steroid therapy is not indicated before clinical evaluation is complete
Regimen:
* 15mg x 3 weeks
* 12.5mg x 3 weeks
* 10mg x 4-6 weeks
* Then decrease by 1mg q4-8 weeks
PMR
Referral
Atypical presentation
* Age <50
* Chronic onset
* Lack of shoulder involvement
* Lack of stiffness
* “red flags” prominent systemic features
* Extreme elevation of ESR/CRP (>100)
Treatment dilemmas
* Incomplete response to steroids
* Unable to decrease steroids (unsuccessful wean)
* Need for prolonged steroid therapy (>2 years)
* Contra-indication to steroid therapy
