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Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines

Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines. HDR Wednesday 23 rd November 2011 By Dr Mahya Mirfattahi GP Registrar. Core inclusion criteria. Age >50 years, duration >2 weeks Bilateral shoulder or pelvic girdle aching, or both Morning stiffness duration of >45mins

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Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines

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  1. Polymyalgia RheumaticaA micro-teach of BSR & BHPR guidelines HDR Wednesday 23rd November 2011 By Dr Mahya Mirfattahi GP Registrar

  2. Core inclusion criteria • Age >50 years, duration >2 weeks • Bilateral shoulder or pelvic girdle aching, or both • Morning stiffness duration of >45mins • Evidence of an acute-phase response

  3. PMR • Can be diagnosed with normal inflammatory markers, if • classical clinical picture • Response to steroids • Should be referred for specialist assessment

  4. Core exclusion criteria • Active infection • Active cancer • Active GCA • Presence of following decreases probability of PMR, therefore should be excluded • Other inflammatory rheumatic conditions • Drug-induced myalgia • Chronic pain syndromes • Endocrine disease • Neurological conditions e.g. Parkinsons disease

  5. Assess for evidence of GCA • Abrupt-headache (temporal) and usually with temporal tenderness • Visual disturbance, including diplopia • Jaw or tongue claudication • Prominence, beading or diminished pulse on examination of temporal artery • Upper cranial nerve palsies • Limb claudication or other evidence of large-vessel involvement

  6. Recommended baseline investigations • FBC • ESR/CRP • U&E, LFT, Calcium, CK, TSH • Protein electrophoresis & BJP • RF (ANA & anti-CCP may be considered) • Dipstick urine • CXR

  7. Early specialist referral • Age <60 years • Chronic onset >2 months • Lack of shoulder involvement • Lack of inflammatory stiffness • Prominent systemic features weight loss, night pain, neurological signs • Features of other rheumatic disease • Normal of extremely high acute-phase response • Management dilemmas • Poor response to treatment, needing treatment >2 years, relapses, corticosteroid contraindicated or not tolerated

  8. Treatment • Low-dose steroid • Suggested regimen • Daily prednisolone 15mg for 3 weeks • Then 12.5mg for 3 weeks • Then 10mg for 4-6 weeks • Then reduce by 1mg every 4-8 weeks • Alternative is methylprednisolone • Milder cases or steroid-related complications • Initial dose 120mg every 3-4 weeks, reducing by 20mg every 2-3 months • Usually 1-2 years of treatment needed • If >2 years refer

  9. Recommended use of bone protection • Individual with high fracture risk e.g. aged >65 years or prior fragility fracture • Bisphosphonate with calcium and vitamin D • DEXA not needed • Other individuals • Calcium and vitamin D supplementation when starting steroid therapy • DEXA scan recommended • A bone-sparing agent if T-score <-1.5

  10. Monitoring • Follow up schedule • Weeks 0,1-3, 6 • Months 3,6,9, 12 in first year • At each visit assess • Response to treatment: proximal pain, fatigue and morning stiffness • Complications of disease including symptoms of GCA • Steroid-related adverse effects • Atypical features or those suggesting an alternative diagnosis • FBC, ESR/CRP, U&E, glucose • Usually 1-3 years of treatment

  11. Relapses • Not just rise in ESR/CRP • Clinical features of GCA: treat as GCA (40-60mg prednisolone & urgent referral) • Clinicial features of PMR: increase prednisolone to previous higher dose • Single IM injection of methylprednisolone can also be used • Further relapses: DMARD after 2 relapses

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