Polymyalgia Rheumatica

Question 1

What is polymyalgia rheumatica (PMR)?

Answer 1

A chronic inflammatory condition presenting with stiffness and pain of the proximal large joints

PMR has a prevalence of approximately 1% in the UK.

Question 2

At what age does the incidence of PMR peak?

Answer 2

70-80 years old

PMR is very rare in individuals under 50.

Question 3

Which gender makes up the majority of PMR cases?

Answer 3

Women

Incidence is significantly higher in patients with Northern European ancestry.

Question 4

What percentage of PMR patients develop

Answer 4

15-20%

PMR affects up to 60% of patients with giant cell arteritis.

Question 5

What is the key symptom of PMR?

Answer 5

RAPID ONSET aching morning stiffness that is Bilateral shoulder, neck, and pelvic girdle pain

Affects proximal muscles

Question 6

List some systemic symptoms common in PMR.

Answer 6

• Low-grade fevers
• Loss of appetite
• Weight loss
• Malaise
• Depression

Muscle power is usually preserved unless there is disuse atrophy.

Question 7

What basic investigations should be undertaken in all PMR patients?

Answer 7

• Urine dipstick
• ESR and/or CRP
• FBC
• U&Es
• LFTs
• Bone profile
• Creatine kinase
• Thyroid function tests
• Protein electrophoresis
• Rheumatoid factor
• HbA1c
• Chest X-ray

These tests help rule out differentials and assess the patient’s condition.

Question 8

What is the usual steroid regimen for PMR treatment?

Answer 8

15mg of oral prednisolone once a day

Patients should be reassessed after a week to assess treatment response.

Question 9

True or false: Patients with PMR should never stop steroids suddenly due to the risk of adrenal insufficiency.

Answer 9

TRUE

Important management considerations include giving patients a steroid card.

Question 10

What should be monitored in patients receiving long-term steroids for PMR?

Answer 10

• Blood pressure
• Glucose

Hypertension and hyperglycaemia are common side effects.

Question 11

List the red flag signs that warrant referral to rheumatology for PMR.

Answer 11

• Weight loss
• Night pain
• Aged under 60
• No shoulder/pelvic girdle pain
• Chronic onset of symptoms
• Atypical inflammatory markers
• Limited or no response to steroid treatment
• Steroids required for over 2 years
• Unable to wean steroids without relapses
• Significant adverse effects with steroids
• Suspected giant cell arteritis

Atypical clinical features may indicate a need for further assessment.

Question 12

What secondary care management options are available for PMR?

Answer 12

• Methotrexate
• Azathioprine
• Physiotherapy

These options may be beneficial for managing PMR.

Question 13

What investigations indicate polymylalgia rheumatic a?

Answer 13

raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal

Question 14

What should indicate alternate diagnosis of poly myalgia?

Answer 14

Failure to respond to steroids

Question 15

What should raised creatine kinase raise suspicion for?

Answer 15

Myostitis

Question 16

What should raised calcium raise suspicion for?

Answer 16

Myeloma

Question 17

How to differentiate myosotis from course?

Answer 17

Myositis is often painless but associated with prominent muscle weakness on examination; skin changes are seen in dermatomyositis and CK will be significantly increased

Question 18

What complication of PMR should be excluded before initiating treatment?

Answer 18

Giant cell arteritis as it requires higher steroid doses

Question 19

What is the typical drug course of steroids?

Answer 19

4-8 weeks followed by gradual tapering over 1-2 years, the reduction in dose is guided by symptom control & inflammatory marker trends (CRP, ESR

Question 20

What are the blood test findings for poly myalgia rheumatica?

Answer 20

Normal creatine kinase
Raised ESR and CRP
Normal anti-CCP

Question 21

How to differentiate between poly myalgia and polymyositis?

Answer 21

Polymyositis is an inflammatory myopathy that causes proximal muscle weakness rather than muscle aches