Polymyalgia Rheumatica

• What is polymyalgia rheumatica?

  Chronic inflammatory condition

  Causes pain & stiffness in shoulder & pelvic girdle

  Strong association with giant cell arteritis

  More common in older white pts
• Who does polymyalgia rheumatica commonly affect?

  Over 50s
• What are the RFs of polymyalgia rheumatica?

  Age > 50

  Giant cell arteritis
• What are the signs & symptoms of polymyalgia rheumatica?

  Pain & stiffness of large joints (shoulders, pelvic girdle, neck)

  • worse in the morning
  • worse after rest/inactivity
  • interfere with sleep
  • take at least 45 mins to ease in morning
  • somewhat improve with activity
  • may radiate to elbows/knees

  Weight loss

  Fatigue

  Low grade fever

  Muscle tenderness

  Carpal tunnel syndrome

  Peripheral oedema

  Muscle weakness
• When do pts with polymyalgia rheumatica need a referral to a rheumatologist?

  < 60 yrs

  Red flags

  • weight loss
  • night pain
  • neurological features

  Do not have core symptoms of polymyalgia rheumatica

  • bilateral shoulder/pelvic girdle pain
  • > 45 mins morning stiffness)

  Unusual features of polymyalgia rheumatica

  • normal/very high CRP/ESR
  • chronic onset of symptoms
  • limited response to steroids
• What are the DDx of polymyalgia rheumatica?

  OA

  RA

  SLE

  Statin-induced myopathy

  Myositis

  Cervical spondylosis

  Adhesive capsulitis (frozen shoulder)

  Hyperthyroidism/hypothyroidism

  Osteomalacia

  Fibromyalgia

  Lymphoma or leukaemia

  Myeloma
• What are the Inx for polymyalgia rheumatica?

  Obs

  Full Hx & examination

  Urine dip

  Bloods (CRP, FBC, U&Es, LFTs, TFTs, bone profile, serum protein electrophoresis, creatine kinase, RF, ANA (for SLE), HbA1c (prior to starting steroids))

  Consider CXR
• How is polymyalgia rheumatica diagnosed?

  Based on...

  • clinical presentation
  • response to steroids
  • excluding differentials
• What is the treatment of polymyalgia rheumatica?

  Corticosteroids (15 mg prednisolone daily, follow up after 1 week)

  -> pt w/polymyalgia rheumatica will have dramatic improvement of symptoms within 1 wk

  -> steroid treatment usually lasts 1-2 trs, then reducing regime
• What reducing regime does NICE suggest in polymyalgia rheumatica?

  15mg until the symptoms are fully controlled, then

  12.5mg for 3 weeks, then

  10mg for 4-6 weeks, then

  Reducing by 1mg every 4-8 weeks
• What is the additional management for pts on long-term steroids?

  Don't STOP

  Don't abruptly stop steroids -> risks adrenal crisis

  Sick day rules (steroid dose increased if pt becomes unwell)

  Treatment card (to alert others they are steroid-dependent)

  Osteoporosis prevention (bisphosphonates, calcium & vitamin D)

  PPI (for gastro-protection)
• What are the possible complications of polymyalgia rheumatica?

  Chronic relapsing course

  Corticosteroid risks

  Giant cell arteritis