Transcript Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines

Polymyalgia
Rheumatica
A micro-teach of BSR & BHPR
guidelines
HDR Wednesday 23rd November
2011
By Dr Mahya Mirfattahi GP Registrar
Core inclusion criteria
O Age >50 years, duration >2 weeks
O Bilateral shoulder or pelvic girdle aching, or
both
O Morning stiffness duration of >45mins
O Evidence of an acute-phase response
PMR
O Can be diagnosed with normal inflammatory
markers, if
O classical clinical picture
O Response to steroids
O Should be referred for specialist assessment
Core exclusion criteria
O Active infection
O Active cancer
O Active GCA
O Presence of following decreases probability of
PMR, therefore should be excluded
O Other inflammatory rheumatic conditions
O Drug-induced myalgia
O Chronic pain syndromes
O Endocrine disease
O Neurological conditions e.g. Parkinsons disease
Assess for evidence of GCA
O Abrupt-headache (temporal) and usually
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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 largevessel involvement
Recommended baseline
investigations
O FBC
O ESR/CRP
O U&E, LFT, Calcium, CK, TSH
O Protein electrophoresis & BJP
O RF (ANA & anti-CCP may be considered)
O Dipstick urine
O CXR
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
O Features of other rheumatic disease
O Normal of extremely high acute-phase response
O Management dilemmas
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O Poor response to treatment, needing treatment >2
years, relapses, corticosteroid contraindicated or not
tolerated
Treatment
O Low-dose steroid
O Suggested regimen
O Daily prednisolone 15mg for 3 weeks
O Then 12.5mg for 3 weeks
O Then 10mg for 4-6 weeks
O Then reduce by 1mg every 4-8 weeks
O Alternative is methylprednisolone
O Milder cases or steroid-related complications
O Initial dose 120mg every 3-4 weeks, reducing by
20mg every 2-3 months
O 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 fracture
O Bisphosphonate with calcium and vitamin D
O DEXA not needed
O Other individuals
O Calcium and vitamin D supplementation
when starting steroid therapy
O DEXA scan recommended
O A bone-sparing agent if T-score <-1.5
Monitoring
O Follow up schedule
O Weeks 0,1-3, 6
O Months 3,6,9, 12 in first year
O At each visit assess
O Response to treatment: proximal pain, fatigue and
morning stiffness
O Complications of disease including symptoms of GCA
O Steroid-related adverse effects
O Atypical features or those suggesting an alternative
diagnosis
O FBC, ESR/CRP, U&E, glucose
O Usually 1-3 years of treatment
Relapses
O Not just rise in ESR/CRP
O Clinical features of GCA: treat as GCA (40-
60mg prednisolone & urgent referral)
O Clinicial features of PMR: increase
prednisolone to previous higher dose
O Single IM injection of methylprednisolone
can also be used
O Further relapses: DMARD after 2 relapses