Transcript The relationship between time

History of PMR
1888 First described as senile rheumatic gout (Bruce)
1936 Secondary fibrositis
1945 Periarthrosis humeroscapular
1946 Peri-extra-articular rheumatism
1951 Special arthritis of old age
1952 Myalgic syndrome of aged with systemic reaction
1953 Pseudo-polyarthrite rhizomelique
1954 Anarthritic rheumatoid disease
1950s Henk discovered anti-inflamm effects of prednisolone
1957 Polymyalgia rheumatica (Barber - Manchester)
Diagnostic Criteria
BSR working group (Dasgupta 2008)
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Age >50 years
Shoulder and/or pelvic girdle pain
Morning stiffness >45mins
Duration of 2 weeks at least
ESR>30 mm/hr or CRP >6 mg/l
Jones & Hazleman 1981
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Absence of inflammatory arthritis, RA or malignancy
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Absence of muscle weakness / disease
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Prompt & dramatic response to steroids
Differential Diagnosis
Rheumatoid arthritis
Inflammatory myopathy
Drug-induced myalgia (statins)
Endocrine disease (thyroid, parathyroid, Addison’s)
Malignancy, metastases, myeloma
Occult sepsis
Shoulder capsulitis, rotator cuff disorders
Osteoarthritis, spondylosis
Depressive illness
Parkinsonism
Fibromyalgia or pain syndromes
Multiple pathology
GP or hospital condition?
Management
Start with plain prednisolone 15mg – expect
70% response within one week
Immediate bone protection (alendronate)
Monitor
Clinical : pain stiffness, disability, steroid effects,
other rheumatic problems may intervene
Lab : FBC, esr/CRP, U&E, glucose
When to refer?
Atypical features
Younger patient
Chronic onset
Lack of shoulder involvement
Lack of inflammatory stiffness
“Red flag features” : weight loss, night pain, neuro signs, systemic
features ++
Peripheral arthritis or signs of CTD/muscle disease
Normal or v high acute phase response [esr or CRP ]
Treatment Dilemmas
Incomplete or non-response to steroid
or ill-sustained response
or unable to reduce dose
or C/I to steroids
What’s new?
Strong relationship between starting dose and maintenance dose of steroid
Initial esr correlates with duration of treatment
ESR > CRP for prediction of relapse (also calprotectin from WBC)
Intramuscular methyl-prednisolone (Depomedrone)
Deflazacort - no better than prednisolone
Methotrexate – only small steroid-sparing effect
Etanercept modest effect : Infliximab doesn’t work
Tocilizumab may ameliorate via interleukin-6
PMR with normal esr in 7% : PMR with normal CRP in 1%
Diagnosis & follow-up : GP or hospital
What’s the cause?
Subclinical vasculitis
Extra-capsular oedema on MRI
Subacromial or subdeltoid bursitis on U/S
Glenohumeral inflaamation onU/S
No clinical or lab features to differentiate PMR from RA, although HLS
class II associations are different
Temporal arteritis,
aka. cranial arteritis, giant cell arteritis GCA
• Age >50yrs
• Headache- subacute onset, usually bilateral,
may be unilateral
• Jaw claudication
• Systemic upset; fever, wt loss
• Temporal arteritis = medical emergency
because of risk of sudden irreversible
blindness
Treatment
• Steroids – Prednisolone high dose 1mg/kg
or intravenous methylpred
- start before biopsy
• Steroid sparing agents sometimes used in
chronic phase (MTx azathioprine)
• Aspirin
Duration of steroid therapy
• Most patients one to two years
• No consistently reliable predictors of
the duration of therapy have been found.
NEJM 2002;347:261-271
• Steroid doses to be tapered according to
inflammatory markers and clinical picture.
• IL6 is a better predictor of disease flare and ?can
be used to monitor disease activity and gauge rate
of steroid reduction
Weyand CM, HunderGM Arthritis Rheum 2000;43:1041-1048
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