PMR & GCA

Question 1

What is the link between PMR and GCA?

Answer 1

Unknown whether they’re part of the same condition or are distinct conditions

Often co-exist and both respond to steroids

Many who have one develop the other

Question 2

What is GCA?

Answer 2

Giant cell arteritis

Immune mediated vasculitis affected medium and large sized arteries

Particularly the carotid and its extracranial branches, such as temporal

Can potentially cause sudden bilateral vision loss so considered a medical emergency

Question 3

Risk factors of GCA?

Answer 3

Northern European descent

Female

60-80 years old

Genetic

PMR

Question 4

Presentation of GCA?

Answer 4

Headache

Temporal artery and scalp tenderness
Can’t brush hair

Jaw claudication gradual onset

Amaurosis fugax (transient visual loss) or visual loss usually in one eye

Fever, malaise, fatigue

Features of PMR: stiffness, pain

Question 5

Why does GCA cause visual disturbances?

What visual disturbances?

Answer 5

Amaurosis fugax (curtains, transient visual loss)

Permanent visual loss

Diplopia

Because of inflammation of branches of the ophthalmic nerve, resulting in ischaemic optic neuritis

Question 6

What might you find on examination of GCA patient?

Answer 6

Palpation of temporal artery: absent pulse, beaded, tender, enlarged

Diplopia
Visual loss

Carotid bruit

Question 7

Investigations of GCA?

Answer 7

ESR above 50
(CRP)

FBC: thrombocytosis, anaemia

LFTs: raised alk phos

Urgent temporal artery biopsy (within 7 days)

Question 8

Management of GCA?

Answer 8

Urgent referral for biopsy and treatment

Start high dose corticosteroids immediately on suspicion of GCA

• 40mg pred
• 60mg pred if claudication
• IV methylpred if visual symptoms

Typically continue on steroids for 2 years, reducing dose

Low dose aspirin 75mg daily

Question 9

When managing a patient with GCA, what other drugs might you want to prescribe?

Answer 9

They’re on steroids and NSAIDs

PPI
Osteoporosis prophylaxis (bisphosphonate)

Question 10

Side effects of long term steroid use?

Answer 10

Diabetes
Fragile skin
Bleeding: easy bruising
Osteoporosis
Cushing's syndrome
Emotional: insomnia, depression, mania
Infections

Question 11

What is PMR?

Answer 11

Inflammatory condition of unknown cause

Causing severe bilateral pain

And morning stiffness of shoulder, neck and pelvis

Linked with GCA

Question 12

Presentation of PMR?

Answer 12

Over 50

2 weeks of bilateral aching, tenderness, morning stiffness

In shoulders, proximal limb muscles

Also polyarthritis, tenosynovitis, carpal tunnel

Fever, fatigue, weight loss, anorexia

Question 13

Investigations of PMR?

What level will be normal?

Answer 13

Raised CRP and ESR

Raised ALP in some

CK levels normal (abnormal in myositis and myopathies)

Ensure no GCA

Question 14

Management of PMR?

Answer 14

Prednisolone 15mg

Should see a dramatic response in 1 week

Then reduce dose by 1mg per month

Treat for 1-2 years

Not as much of a rush in PMR as in GCA, can take time to confirm diagnosis

Physio and OT

Question 15

How should PMR patients be monitored?

Answer 15

Symptom severity

Ask about GCA symptoms

Steroid side effects

ESR and CRP