Polymyalgia Rheumatica

A micro-teach of BSR & BHPR guidelines

HDR Wednesday 23rd November 2011

By Dr Mahya Mirfattahi GP Registrar

Core inclusion criteriaO Age >50 years, duration >2 weeksO Bilateral shoulder or pelvic girdle

aching, or bothO Morning stiffness duration of

>45minsO Evidence of an acute-phase response

PMR O Can be diagnosed with normal

inflammatory markers, if O classical clinical pictureO Response to steroidsO Should be referred for specialist

assessment

Core exclusion criteriaO Active infectionO Active cancerO Active GCAO Presence of following decreases probability

of PMR, therefore should be excludedO Other inflammatory rheumatic conditionsO Drug-induced myalgiaO Chronic pain syndromesO Endocrine diseaseO Neurological conditions e.g. Parkinsons

disease

Assess for evidence of GCA

O Abrupt-headache (temporal) and usually with temporal tenderness

O Visual disturbance, including diplopiaO Jaw or tongue claudicationO Prominence, beading or diminished

pulse on examination of temporal artery

O Upper cranial nerve palsiesO Limb claudication or other evidence of

large-vessel involvement

Recommended baseline investigations

O FBCO ESR/CRPO U&E, LFT, Calcium, CK, TSHO Protein electrophoresis & BJPO RF (ANA & anti-CCP may be

considered)O Dipstick urineO CXR

Early specialist referral O Age <60 yearsO Chronic onset >2 monthsO Lack of shoulder involvementO Lack of inflammatory stiffnessO Prominent systemic features weight loss, night

pain, neurological signsO Features of other rheumatic diseaseO Normal of extremely high acute-phase

responseO Management dilemmas

O Poor response to treatment, needing treatment >2 years, relapses, corticosteroid contraindicated or not tolerated

Treatment O Low-dose steroidO Suggested regimen

O Daily prednisolone 15mg for 3 weeksO Then 12.5mg for 3 weeksO Then 10mg for 4-6 weeksO Then reduce by 1mg every 4-8 weeks

O Alternative is methylprednisoloneO Milder cases or steroid-related complicationsO Initial dose 120mg every 3-4 weeks,

reducing by 20mg every 2-3 monthsO Usually 1-2 years of treatment needed

O If >2 years refer

Recommended use of bone protection

O Individual with high fracture risk e.g. aged >65 years or prior fragility fractureO Bisphosphonate with calcium and vitamin

DO DEXA not needed

O Other individualsO Calcium and vitamin D supplementation

when starting steroid therapyO DEXA scan recommendedO A bone-sparing agent if T-score <-1.5

MonitoringO Follow up schedule

O Weeks 0,1-3, 6O Months 3,6,9, 12 in first year

O At each visit assessO Response to treatment: proximal pain,

fatigue and morning stiffnessO Complications of disease including symptoms

of GCAO Steroid-related adverse effectsO Atypical features or those suggesting an

alternative diagnosisO FBC, ESR/CRP, U&E, glucoseO Usually 1-3 years of treatment

RelapsesO Not just rise in ESR/CRPO Clinical features of GCA: treat as GCA

(40-60mg prednisolone & urgent referral)O Clinicial features of PMR: increase

prednisolone to previous higher doseO Single IM injection of methylprednisolone

can also be usedO Further relapses: DMARD after 2 relapses