Polymyalgia rheumatica

Polymyalgia rheumatica typically manifests as inflammatory pain 
in the shoulder and / or pelvic girdles in a patient over 50 yrs of age

t ( PMR ) is the most common inflammatory rheumatic disease 
in the elderly and is one of the biggest indications for long term steroid therapy

Pathophysiology- Poorly understood Polygenic inflammatory disorders ( PMR & GCA ) with several genetic & environmental factors likely influencing patient susceptibility & disease severity Closely linked to GCA ( Giant cell arteritis ) About one half of patients affected by GCA also meet diagnostic
criteria of PMR – however only about 10 % of patients with PMR
also have GCAso it is thought that mechanisms which contribute to GCA may be involved as genetically predisposed individual – an environment factor possibly virusPathologically GCA and PMR- similar
Main difference – absence of significant vascular involvement in PMR
 PMR- no evidence of disease in muscle biopsy A mild synovitis with macrophages and CD4 + T cell infiltration in the glenohumeral jt ( systemic macrophages and T-cell activation are seen in both GCA and PMR ) Increased pro-inflammatory cytokines and melatonin

Epidemiology-Highest in individuals with Northern European descent – more in Scandinavian people than other white population Women twice more likely to be diagnosed Increases with age in both sexes until age 80 Seldom diagnosed in people younger than 50 yrs of age – median age of diagnosis is 72 yrs UK – annual incidence is 84 per 100,000 No increase in mortality associated with PMR

Complications long term steroid therapy- Osteoporosis Weight gain Skin bruising Raised BP Impaired blood glucose Depression Cardiac failure Susceptibility to infections Cataracts Glaucoma Cushing’s syndrome

Presentation –Bilateral shoulder pain and / or pelvic
girdle pain Morning stiffness > 45 min Abrupt onset Age > 50 yrs Duration > 2 weeks Acute phase response – raised ESR / CRP Rapid response to prednisolone



ESR is sensitive for PMR
 but not specific- frequently 
greater than 40 &
 can exceed 100

Mildly elevated in 7-20 % and
 can be occasionally normal-
 a rapid response to steroids
 can suggest PMR in 
such cases

Low grade fever Anorexia Weight loss Malaise fatigue and depression Difficulty rising from bed in morning Difficulty getting up from toilet or out of a chair Synovitis of proximal joints and periarticular structures Peripheral arthritis ( in 25 % patients ) Muscle stiffness after prolonged inactivity

Investigations –FBC – mild normocytic normochromic anaemia is common ESR / CRP / Plasma viscosity U&E LFT – AlkPo4 may be mildly elevated Calcium Protein electrophoresis & Bence Jones Protein -Normal TFT Creatinine kinase – is normal Rheumatoid factor ( Anti- CCP if available ) CXR if significant systemic symptoms Urine dipstick MRI- bursitis joint effusions

ESR > 40 is considered significant ESR < 40 can be present in 7-20 % of patients Patients with low ESR have typically lower frequency of systemic symptoms ESR is sensitive for PMR but not specific CRP is also typically elevated

Differential- Cervical & lumbar spondylosis Osteoarthritis Frozen shoulder
RC disorders Thyroid disorders Parathyroid disease leading to hypercalcaemia Diabetes Viral illness Chronic osteomyelitis Tuberculosis Infective endocarditis Septic arthritis Rh arthritis Polymyositis SLE Spondyloarthropathy Multiple myeloma Acute leukaemia Lymphoma Solid tumors -Lung m renal , prostate GCA or temporal arthritis Drug induced – eg statins Osteomalacia Fibromyalgia Chronic fatigue syndrome

Referral age < 60 chronic onset lack of shoulder movements no inflammatory stiffness red flags 
♦ prominent systemic features
♦ weight loss
♦ night pain
♦ neurological signs peripheral arthritis Suspected conn tissue / muscle dis normal or very high CRP Incomplete or non- specific response to steroids Ill sustained response to steroids Unable to reduce steroids at reasonable intervals without causing relapse Steroids use beyond 2 yrs Contraindication to steroid therapy

LINKS AND RESOURCES

PATIENT INFORMATION

Charity PMR GCA http://www.pmrgca.co.uk/content/home-page

American College of Rheumatology information for patients https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Polymyalgia-Rheumatica

Versus Arthritis webpage on PMR https://www.versusarthritis.org/about-arthritis/conditions/polymyalgia-rheumatica-pmr/
Versus arthritis booklet on PMR ( 20 pages ) https://www.versusarthritis.org/media/1322/polymyalgia-rheumatica-information-booklet.pdf

A comprehensive patient information page by Vasculitis Foundation https://www.vasculitisfoundation.org/education/forms/polymyalgia-rheumatica/#disease-faq

Wish to print ? 2 page info from Arthritis Australia https://arthritissa.org.au/downloads/2015-05-11_223155_Polymyalgia-rheumatica.pdf

Arthritis foundation on PMR https://www.arthritis.org/diseases/polymyalgia-rheumatica

Vasculitis Org on PMR https://www.vasculitis.org.uk/about-vasculitis/polymyalgia-rheumatica

NHS inform on PMR https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/polymyalgia-rheumatica

Patient steroid card http://www.nmouk.nhs.uk/downloads/Steroid-card.pdf

INFORMATION FOR HEALTH CARE PROFESSIONALS ON POLYMYALGIA RHEUMATICA

Recommendations for the Management of
Polymyalgia Rheumatica
A European League Against Rheumatism/American College of Rheumatology
Collaborative Initiative https://www.rheumatology.org/Portals/0/Files/2015%20PMR%20guidelines.pdf

British Society of Rheumatology -BSR and BHPR guidelines for the management of polymyalgia rheumatica https://academic.oup.com/rheumatology/article/49/1/186/1789113

A good plain language article from Prescriber on Diagnosis and management of PMR https://www.prescriber.co.uk/article/diagnosis-and-management-of-polymyalgia-rheumatica/

References

1. Diagnosis and management of polymyalgia rheumatica Royal College of Physicians June 2010 https://www.rcplondon.ac.uk/guidelines-policy/diagnosis-and-management-polymyalgia-rheumatica
2. Dejaco, C., Singh, Y.P., Perel, P., Hutchings, A., Camellino, D., Mackie, S., Abril, A., Bachta, A., Balint, P., Barraclough, K., Bianconi, L., Buttgereit, F., Carsons, S., Ching, D., Cid, M., Cimmino, M., Diamantopoulos, A., Docken, W., Duftner, C., Fashanu, B., Gilbert, K., Hildreth, P., Hollywood, J., Jayne, D., Lima, M., Maharaj, A., Mallen, C., Martinez‐Taboada, V., Maz, M., Merry, S., Miller, J., Mori, S., Neill, L., Nordborg, E., Nott, J., Padbury, H., Pease, C., Salvarani, C., Schirmer, M., Schmidt, W., Spiera, R., Tronnier, D., Wagner, A., Whitlock, M., Matteson, E.L. and Dasgupta, B. (2015), 2015 Recommendations for the Management of Polymyalgia Rheumatica: A European League Against Rheumatism/American College of Rheumatology Collaborative Initiative. Arthritis & Rheumatology, 67: 2569-2580. doi:10.1002/art.39333
3. Oct Arthritis research UK : Polymyalgia rheumatica 

4. Polymyalgia rheumatica   Published:July 31, 2017DOI:https://doi.org/10.1016/S0140-6736(17)31825-1 Prof Miguel A González-Gay, MD Eric L Matteson, MDSantos Castañeda, MD SEMINAR| VOLUME 390, ISSUE 10103, P1700-1712, OCTOBER 07, 2017

5. Polymyalgia Rheumatica Ferri’s Clinical Advisor 2018

6. Polymyalgia rheumatica in primary care: managing diagnostic uncertainty BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5199 (Published 07 October 2015)

7. BMJ Best Practice – Polymyalgia Rheumatica https://bestpractice.bmj.com/topics/en-gb/153
8. Polymyalgia rheumaticaa -E Medicine Updated Sep 2016
9. Helliwell, Toby et al. “Polymyalgia rheumatica: diagnosis, prescribing, and monitoring in general practice.” The British journal of general practice : the journal of the Royal College of General Practitioners vol. 63,610 (2013): e361-6. doi:10.3399/bjgp13X667231
10. CKS NHS Polymyalgia rheumatica Aug 2013https://cks.nice.org.uk/polymyalgia-rheumatica
11. Martin Soubrier, Jean-Jacques Dubost, Jen-Michel Ristori,
    Polymyalgia rheumatica: diagnosis and treatment,
    Joint Bone Spine,
    Volume 73, Issue 6,
    2006,
    Pages 599-605,
    ISSN 1297-319X,
    https://doi.org/10.1016/j.jbspin.2006.09.005.
12. Understanding and managing polymyalgia rheumatica Medicine Today 2014 : 15 (9) : 47-51
13. Stat Pearls PMR via https://www.ncbi.nlm.nih.gov/books/NBK537274/