Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines HDR Wednesday 23rd November 2011 By Dr Mahya Mirfattahi GP Registrar

Core inclusion criteria Age >50 years, duration >2 weeks Bilateral shoulder or pelvic girdle aching, or both Morning stiffness duration of >45mins Evidence of an acute-phase response

PMR Can be diagnosed with normal inflammatory markers, if classical clinical picture Response to steroids Should be referred for specialist assessment

Core exclusion criteria Active infection Active cancer Active GCA Presence of following decreases probability of PMR, therefore should be excluded Other inflammatory rheumatic conditions Drug-induced myalgia Chronic pain syndromes Endocrine disease Neurological conditions e.g. Parkinsons disease

Assess for evidence of GCA Abrupt-headache (temporal) and usually 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 large-vessel involvement

Recommended baseline investigations FBC ESR/CRP U&E, LFT, Calcium, CK, TSH Protein electrophoresis & BJP RF (ANA & anti-CCP may be considered) Dipstick urine 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 Features of other rheumatic disease Normal of extremely high acute-phase response Management dilemmas Poor response to treatment, needing treatment >2 years, relapses, corticosteroid contraindicated or not tolerated

Treatment Low-dose steroid Suggested regimen Daily prednisolone 15mg for 3 weeks Then 12.5mg for 3 weeks Then 10mg for 4-6 weeks Then reduce by 1mg every 4-8 weeks Alternative is methylprednisolone Milder cases or steroid-related complications Initial dose 120mg every 3-4 weeks, reducing by 20mg every 2-3 months Usually 1-2 years of treatment needed If >2 years refer

Recommended use of bone protection Individual with high fracture risk e.g. aged >65 years or prior fragility fracture Bisphosphonate with calcium and vitamin D DEXA not needed Other individuals Calcium and vitamin D supplementation when starting steroid therapy DEXA scan recommended A bone-sparing agent if T-score <-1.5

Monitoring Follow up schedule At each visit assess Weeks 0,1-3, 6 Months 3,6,9, 12 in first year At each visit assess Response to treatment: proximal pain, fatigue and morning stiffness Complications of disease including symptoms of GCA Steroid-related adverse effects Atypical features or those suggesting an alternative diagnosis FBC, ESR/CRP, U&E, glucose Usually 1-3 years of treatment

Relapses Not just rise in ESR/CRP Clinical features of GCA: treat as GCA (40-60mg prednisolone & urgent referral) Clinicial features of PMR: increase prednisolone to previous higher dose Single IM injection of methylprednisolone can also be used Further relapses: DMARD after 2 relapses