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Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis

Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis. Dr Martin Lee MRCP(Rheum) Rheumatology Consultant, Honorary Senior Clinical Lecturer & Associate Clinical Sub Dean Freeman Hospital, Newcastle. PMR: Pitfalls. Are you sure the diagnosis is right?

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Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis

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  1. Rheumatology for GP Trainees:Polymyalgia Rheumatica & Giant Cell Arteritis Dr Martin Lee MRCP(Rheum) Rheumatology Consultant, Honorary Senior Clinical Lecturer & Associate Clinical Sub Dean Freeman Hospital, Newcastle

  2. PMR: Pitfalls • Are you sure the diagnosis is right? • Is the patient on the right treatment? • Steroids aren’t working? • Can’t get the steroid dose down? • Complications of the disease or treatment?

  3. PMR: Bird 1979 Diagnostic Criteria • 3 of the following must be present: • Bilateral shoulder pain or stiffness • Onset < 2 weeks • ESR > 40 • Morning stiffness > 1hr • Age >65 • Weight loss • Bilateral upper arm tenderness

  4. PMR • Epidemiology: • Average age onset 70, never <50 • Incidence in >50, 1/1,000 • Female 3:1 Male • Natural Progression • Self limiting (chronic relapsing), morbidity • Clinical Features • Bilateral/symmetrical shoulder/pelvic stiffness > pain • Morning stiffness >45minutes (and inactivity stiffness) • Systemic symptoms, association with GCA • Painful restriction active/passive movements • Not weakness (NB. pain and stiffness) • Does not involve distal joints • Inflammatory markers

  5. PMR: Management • Prednisolone 15mg (can escalate to 20mg) • If patient responds clinically and laboratory markers normalise then gradually taper steroid dose unless relapse occurs (clinical rather than laboratory) • 70% global clinical improvement after 1 week • Normal acute phase response after 3 weeks • 15mg 1/12, 12.5mg 1/12, 10mg 1/12 • Then reduce by 1mg/day every 4-6 weeks • 12 – 18 months

  6. Case History 1: Mrs KF • January 2010: • 82-year old female presented to GP • Buttock pain and weakness • Pain in shoulders • Diagnosed with PMR and started on steroid ?dose • October 2010: • Admitted via AMU • Upper back pain (not stiffness) and leg weakness • 3/12 weight loss and low appetite • CRP 336 • Prednisolone increased to 30mg due to ‘flare of PMR’ and referred to Rheumatology

  7. Case History 1: Mrs KF • Urinalysis blood 2+, protein 1+ • Vasculitis screen (cANCA 1:320, PR3 positive) • Renal biopsy: Limited Wegener’s granulomatosis • Prednisolone 100mg alt days, cyclophosphamide

  8. When is PMR not PMR? • Inflammatory conditions: • RA • Dermatomyositis / Polymyositis • Vasculitis • Late onset SpA (ie. AS, PsA)

  9. When is PMR not PMR? • Non-Inflammatory conditions: • OA • Rotator cuff disease • Adhesive capsulitis • Bursitis (ie. subacromial bursitis) /tendonitis • Spinal spondylosis • Hypothyroidism • Infection (ie. infectious endocarditis) • Malignancy (ie. lung / myeloma) • Paraneoplasia • Parkinsonism • Chronic pain syndrome / Fibromyalgia • Osteomalacia • Hypo / hypercalcaemia • Drug induced (statins)

  10. Bilateral shoulder OA and adhesive capsulitis

  11. Investigations • FBC • ESR/CRP/plasma viscosity • U&E • LFT • TSH • CK • Calcium, ALP • Protein electropheresis • RF • Urine Dipstick • ?ANA • ?Imaging (ie. CXR, shoulders)

  12. GCA: ACR 1990 Classification Criteria • 3 of the 5 criteria (sensitivity 94%, specificity 91%): • Age at onset ≥ 50 years • New headache • Temporal artery tenderness or loss of pulsation • ESR ≥ 50mm/hr • Abnormal temporal artery biopsy

  13. GCA: Temporal Artery Biopsy • A biopsy may not be required in all cases but can be helpful • Up to 6 weeks after treatment • Steroids should not be withheld • Positive in 70% of patients with GCA (20% of patients with PMR): • ?Diagnosis / alternative diagnosis • ?Diagnosis retrospectively • ?Initial steroid dose • Classification vs diagnostic criteria

  14. GCA: Ultrasound

  15. GCA: Management • In the absence of visual symptoms, immediately treat with 40-60mg prednisolone (40mg, 30mg, 20mg, 17.5mg, 15mg, 12.5mg, 10mg) • Visual symptoms (Ophthalmology, IV methylprednisolone) • Aspirin, bisphosphonates, calcium/vitamin D, PPI • Permanent visual loss 7-14% due to AION • Other complications include aortitis (15%)

  16. Royal College of Physicians. Glucocorticoid-induced osteoporosis: Guidelines for prevention and treatment Age 65 Age <65 Previous Fragility Fractures or incidental fragility fracture on treatment Investigations No Previous Fragility Fractures Measure BMD DXA T Score Hip ± Spine >0 0 to -1.5 -1.5 or lower TREAT General Measures General Measures Rpt DXA 1-3yrs

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