Core Diagnostic criteria (essential)



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Polymyalgia Rheumatic (PMR) & Giant Cell Arteritis (GCA) for GPs


PMR

Core Diagnostic criteria (essential):


  • Age >50 years, duration >2 weeks

  • Bilateral shoulder or pelvic girdle aching, or both

  • Morning stiffness for >45 minutes

  • Evidence of an acute-phase response (e.g. Raised ESR/CRP)

Patient often feels ill.

Examination – range of movement is good.

Differentials


  • Viral illness, polymyositis, fibromyalgia.

  • EXCLUDE GCA headaches and jaw claudication.

Investigations


  • FBC, ESR, CRP, U&Es, LFTs, TFTs,

  • bone profile, protein electrophoresis / urinary Bence Jones protein. A urine dipstick should also be checked for blood and protein.

  • CK (polymyositis – although rare)

  • ANA, RhF and antiCCP (Rheumatoid arthritis can sometimes present in a similar manner to PMR)

  • A CXR should be considered to exclude malignancy.

Treatment - steroids


Prescribe daily prednisolone 15 mg for three weeks, then:

  • 12.5 mg for three weeks

  • 10 mg for 4-6 weeks

  • Then reduction of 1 mg every 4-8 weeks or alternate day reductions (e.g. 10/7.5 mg on alternate days etc). Patients often find it hard to reduce the dose of prednisolone below 7.5 mg per day.

  • If over age 65 – bisphosphonate + calcichew D3 type thing for bone protection.

  • Patients will be on steroids for months. So watch for weight gain, diabetes, osteoporosis, upper GO pain, HTN , lipid dysfunction.

Often immediate improvement with steroids (dramatic, compared to OA and RhA).

  • If > 70% global response in 1 week  diagnosis is likely to be PMR

  • If <70% response  increasing dose of steroid up to 20 mg prednisolone

  • If still <70% response, reconsider the diagnosis or refer.

Giant Cell Arteritis

Diagnosis


  • Tender swollen temporal arteries (eventually become thickened and pulseless), jaw claudication, headaches

Treatment


  • Low dose aspirin (75mg od) to stop stroke AND

  • Add steroid – prednisolone 60mg od AND

  • Urgent admission (same day) to opth or rheum.

After hospital discharge


Hospital may start iv methylpred (if it is complicated) or continue high dose oral steroids (if it is not complicated). Complicated = jaw or tongue claudication, visual symptoms, including amaurosis fugax.

On discharge, patient will stay on high dose oral steroid until resolution or normalisation of ESR (usually 4+ weeks) after which reduce the steroids as follows



  • reduce 10mg every 2w until patient on 20mg od,

  • then reduce 2.5mg every 2-4w to 10mg,

  • then 1mg reduction every 1-2 months.

  • If relapse at any time, push back up the dose.

Start bone protection- bisphosphonate + calcichew D3 at same time as steroid

It is usual to continue low dose oral steroids for 12-18 months. In some patients it is difficult to stop them after this period. If this is the case, then refer to a specialist so that alternative immuno-suppressants such as methotrexate can be tried


Additional Notes


  • If shoulder pain continues, patient may have co-existing sub-acromial bursitis!

  • Remain vigilant for signs of GCA which occurs in about 5% of patients with PMR.

  • Giant cell arteritis requires treatment with much higher doses of prednisolone (e.g. starting with 60 mg) but even the low doses used in PMR may disguise symptoms



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