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Polymyalgia rheumatica

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Polymyalgia rheumatica

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A review of polymyalgia rheumatica on A4medicine. Closely linked to Giant Cell arteritis the diagnosis and management of PMR can be challenging. Most cases of PMR are diagnosed and managed in the primary care in the UK. Prolong prednisolone therapy is common and the GP should consider osteoporosis prophylaxis/risk assessment in all patients.

Polymyalgia rheumatica typically manifests as inflammatory pain 
in the shoulder and / or pelvic girdles in a patient over 50 yrs of age

t ( PMR ) is the most common inflammatory rheumatic disease 
in the elderly and is one of the biggest indications for long term steroid therapy

Pathophysiology- Poorly understood Polygenic inflammatory disorders ( PMR & GCA ) with several genetic & environmental factors likely influencing patient susceptibility & disease severity Closely linked to GCA ( Giant cell arteritis ) About one half of patients affected by GCA also meet diagnostic
criteria of PMR – however only about 10 % of patients with PMR
also have GCAso it is thought that mechanisms which contribute to GCA may be involved as genetically predisposed individual – an environment factor possibly virusPathologically GCA and PMR- similar
Main difference – absence of significant vascular involvement in PMR
 PMR- no evidence of disease in muscle biopsy A mild synovitis with macrophages and CD4 + T cell infiltration in the glenohumeral jt ( systemic macrophages and T-cell activation are seen in both GCA and PMR ) Increased pro-inflammatory cytokines and melatonin

Epidemiology-Highest in individuals with Northern European descent – more in Scandinavian people than other white population Women twice more likely to be diagnosed Increases with age in both sexes until age 80 Seldom diagnosed in people younger than 50 yrs of age – median age of diagnosis is 72 yrs UK – annual incidence is 84 per 100,000 No increase in mortality associated with PMR

Complications long term steroid therapy- Osteoporosis Weight gain Skin bruising Raised BP Impaired blood glucose Depression Cardiac failure Susceptibility to infections Cataracts Glaucoma Cushing’s syndrome

Presentation –Bilateral shoulder pain and / or pelvic
girdle pain Morning stiffness > 45 min Abrupt onset Age > 50 yrs Duration > 2 weeks Acute phase response – raised ESR / CRP Rapid response to prednisolone



ESR is sensitive for PMR
 but not specific- frequently 
greater than 40 &
 can exceed 100

Mildly elevated in 7-20 % and
 can be occasionally normal-
 a rapid response to steroids
 can suggest PMR in 
such cases

Low grade fever Anorexia Weight loss Malaise fatigue and depression Difficulty rising from bed in morning Difficulty getting up from toilet or out of a chair Synovitis of proximal joints and periarticular structures Peripheral arthritis ( in 25 % patients ) Muscle stiffness after prolonged inactivity

Investigations –FBC – mild normocytic normochromic anaemia is common ESR / CRP / Plasma viscosity U&E LFT – AlkPo4 may be mildly elevated Calcium Protein electrophoresis & Bence Jones Protein -Normal TFT Creatinine kinase – is normal Rheumatoid factor ( Anti- CCP if available ) CXR if significant systemic symptoms Urine dipstick MRI- bursitis joint effusions

Differential- Cervical & lumbar spondylosis Osteoarthritis Frozen shoulder
RC disorders Thyroid disorders Parathyroid disease leading to hypercalcaemia Diabetes Viral illness Chronic osteomyelitis Tuberculosis Infective endocarditis Septic arthritis Rh arthritis Polymyositis SLE Spondyloarthropathy Multiple myeloma Acute leukaemia Lymphoma Solid tumors -Lung m renal , prostate GCA or temporal arthritis Drug induced – eg statins Osteomalacia Fibromyalgia Chronic fatigue syndrome

Referral age < 60 chronic onset lack of shoulder movements no inflammatory stiffness red flags 
♦ prominent systemic features
♦ weight loss
♦ night pain
♦ neurological signs peripheral arthritis Suspected conn tissue / muscle dis normal or very high CRP Incomplete or non- specific response to steroids Ill sustained response to steroids Unable to reduce steroids at reasonable intervals without causing relapse Steroids use beyond 2 yrs Contraindication to steroid therapy

 

 

 

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