Polymyalgia Rheumatica

1. Polymyalgia Rheumatica Practice Meeting 20.8.12 Dr. F. Mayle

2. Polymyalgia Rheumatica, PMR • PMR most common cause of new inflammatory rheumatic disease in older people. • Prevalence 7 per 1,000 people over age of 50yrs. • GP’s diagnose over 80% of cases and manage the majority of cases in primary care. • In 2010, British Society for Rheumatology developed first significant guidelines for 1y and 2y care management of PMR

3. Inclusion criteria for PMR • Diagnosis is based on core inclusion criteria: • Age >50 • Rapid onset, duration over 2 weeks • Bilateral shoulder and/or pelvic girdle pain • Morning stiffness lasting >45mins • Raised ESR/CRP • PMR can be diagnosed without raised inflamm markers if classic symptoms and response to steroids are both present – indication for specialist referral

4. Exclusion criteria • Active giant cell (temporal) arteritis: PMR and GCA frequently co-exist. However, if GCA is present, this condition is the priority and urgent Rx is required • Active cancer • Active infection • The presence of the following conditions reduces the probability of PMR, so you should also exclude: • Other inflamm conditions – RA/SLE • Non-inflamm causes – hip/shoulder, neck OA • Chronic pain syndromes – fibromyalgia • Drug induced myalgia – statins

5. Baseline Investigations in PMR • FBC, ESR/CRP • U+Es, LFTs, calcium • CK • TFTs • Protein electrophoresis • RF • Urine dipstick • CXR – only if prominent systemic symptoms or another cause for concern

6. Initial treatment for PMR • Start prednisolone 15mg daily • Expect a clinical response within one week • Expect lab resolution within 3-4/52 • Continue prednisolone 15mg for 3 weeks • Then 12.5mg for 3 weeks • Then 10mg for 4-6 weeks • Practical tip: often after starting steroid pt’s describe the pain as ‘melting away’. Look for at least a 70% imp’vt in pain. If this isn’t achieved, the steroid dose may not be adequate, in which case increase it to 20mg daily. If a 70% response is still not achieved referral should be considered

7. Bone protection in PMR • If >65yrs OR previous fragility fracture • Start bisphosphonate with calcium and vitamin D supplements • DEXA scan not required • If <65 AND no fragility fracture • Start calcium and vitamin D supplementation • Arrange a DEXA scan to assess bone density

8. How should treatment continue longer term? • Generally, after 10mg, the dose should be reduced by only 1mg every 4 to 8 weeks until medication is stopped • The average length of Rx is 1-2yrs. Initial higher dosing and faster tapering results in increased risk of relapse and more prolonged Rx. • Patient’s requiring rx for longer than 2 yrs should be referred to a specialist. • Practical tip: IM Depo-Medrone may be used in milder cases and may reduce steroid-related complications • Initial dose 120mg every 3 to 4 weeks over 2 to 3 months • Then reduce by 20mg every 2 to 3 months, giving an injection every 4 weeks

9. What monitoring is required? • After initiation of steroid Rx, pt’s should be reviewed within 1 to 3 weeks to confirm a response. Then reviewed at 6 and 12 weeks, then at 3 monthly intervals throughout the period of Rx • At review, pt’s should be assessed for • Symptoms of PMR and benefit of steroids • Complications of disease – GCA can develop even while on Rx • Complications of Rx – steroid induced hypertension, wt gain, DM, osteoporosis, dyslipidaemia • Investigations recommended • FBC • U+Es • ESR/CRP • glucose

10. How should you manage a relapse? • A relapse is defined as a recurrence of PMR symptoms, or the onset of GCA, usually with a rise in ESR/CRP. Isolated rises in ESR/CRP without symptoms do not require incr dose of steroid dose • If a relapse occurs • Increase pred to the previous higher dose and monitor symptoms • A single IM injection of 120mg methylprednisolone may also be used • If the pt has had 2 relapses, they may be considered for DMARD therapy, so refer • If clinical symptoms of GCA develop, high dose steroids and urgent referral are required

11. When should you refer? • Pt’s with a typical clinical picture who respond to steroid Rx can safely be managed in 1y care • Refer if any atypical features, or features that suggest a possible non-PMR diagnosis: • Age <60y • Chronic onset >2mths • Lack of shoulder involvement or inflamm stiffness • Prominent systemic symptoms • Normal or extremely high ESR/CRP Or poor response to Rx, needing Rx for > 2yrs, multiple relapses, steroids contraindicated or not tolerated

12. Giant cell arteritis - GCA • Key features • Abrupt onset headache (usually temporal) and scalp tenderness • Jaw claudication • Visual disturbance, including diplopia • Temporal arteries may be tender, thickened and nodular • NB. very strong assoc with PMR. Up to 20% patients with PMR may develops GCA. Among pt’s with GCA, up to 50% may also have PMR

13. Treatment of GCA • If visual symptoms are present, start pred 60mg and arrange same day ophthalmology rv • If no visual symptoms: • Start pred 40-60mg daily • Start aspirin 75mg unless C.I • Start PPI for gastroprotection • Check ESR/CRP • Refer urgently for specialist assessment • Advise if visual symptoms to develop to seek immediate rv • Assess steroid response in 48 hrs, if poor consider alternative diagnosis • NB: visual loss may occur in 20% of pt’s with GCA. This is almost always before Rx is instigated. However, up to 5% of people may develop visual loss after Rx has commenced, so advice to seek immediate medical advice if symptoms visual symptoms occur