Polymyalgia rheumatica Flashcards by Hannah Nolan

What medication rapid response to in PMR

Corticosteroids

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Where does PMR classically cause pain

Stiffness in shoulder and pelvic girdles

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How differentiate between myositis and PMR

Reduced muscle strength in myositis

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What condition od 15% of PMR patients develop

Giant cell arteritis

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Who does PMR present

> 50 years
70-80 most common
3 x more in women

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Cause of PMR

Environmental factors and genetics
HLA-DRB104 and -DRB101 alleles have been observed, which may increase susceptibility to developing PMR.

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Onset of PMR

Subacute - 2-6 weeks

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Shoulder features in PMR

Tenderness, bursiitis, ROM - localise to neck muscles tenderness

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Systemic sympotms in PMR

Low grade fever, fatigue, anorexia, weight loss, depression

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Features of PMR

Shoulder and pelvic girdle pain
Rapid response to steroids
Systemic symptoms - low grade fever, fatigue, anorexia, weight loss depression
Peripheral oligarticular arthritis - wrist, knees, MCPs

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What would suggest presentation is not PMR

<50 years
Normal inflammatory markers

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What red flags need to screen for in PMR

Paraneoplastic syndrome -
-Resp, urinal haema nd GI systems

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What can delayed presentation of polymyalgia rheumatica cause

Muscle wasting

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Referral guide for PMR to secondary care

<60 years
Red flags of serious pathology incl weight loss, night pain or neuro
Dont have core features eg bilateral shoulder/pelvic girdle pain #>45 mins morning stiffness
Unusual features PMR - normal or v high inflam markers
Chronic onset of symptoms
Limited repsonse to steroids

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Why can RA be confused for PMR

Initial phase can present similarly to PMR - synovitis or clinical features of RA -. refer for RA

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Signs of GCA

Headache, jaw claduciation, visual disturbance

PMR steroid trematne t

Prednisolone 15mg OD
Weaned off gradually dose adjust every 4-8 weeks
Review one week after each adjustment
If frequent relapses or higher risk from adverse effect of steroids - DMARD - methotrexate
Toclixumab - 3rd line

Risks of corticosteroids

Osteoporosis
Increased risk of infection
#T2DM
HPTN
Cataract
Glaucoma
#Skin changes - thinning, bruising

Complications of GCA

Permanent vision loss

Factors increasing risk of relapse

Female sex
High inflam markers
Peripheral arthritis

Course of steroids prognosis

Paitents will relapse at some point
On steroids for 2-3 years

WHat is GCA

Vasculitis of medium and large vessels occuring i over 50s

Why si prompt treatment in GCA vital

Prevent permanent vision loss

GCA features

Rapid onset <1 months
Headache
Jae claudication
Vision eg amourosis fugax, diplopia
Tender, palpable temporal artery
PMR symptoms
Lethargy, depression, low grade fever, night sweats

wHAT IS CAUSE OF MAJORITY OF OCULAR COMPS IN gca

anterior ischemic optic neuropathy - Occlusion of posterior ciliary artery ->ISCHAEMIA OF OPTIC NERVE HEAD

Fundoscopy of anterior ischemic optic neuropathy

Swollen pale disc + blurred margins

Diagnosis of GCA criteria

3 or more of: >50 years New onset of headache Temporal artery abnormality - tenderness, thuckened or reduced pulsation ESR>50 Abnormal artery biopsy Changes consistent with GCA on biopsy

Investigations for GCA

ESR>50 CRP Temporal artery biopsy - skip lesions CK and EMG - normal

Investigations for low clinical probability of GCA

Tmeporal axillary artery US - if postiive biopsy to diangosie within 14 dyas of steroids

Medium vs high clinical probability of temporal arteritis

US prior to biopsy High - US is sifficent alone to diagnose

Central retinal artery occlusion on fundoscopy

Cherry red spot with retinal awhiteneing

When should high dose steroids be used GCA

As soon as diagnosis suspected - before artery biopsy

What steroids are used visual loss vs none

No visual loss - oral pred Evolving visual loss - IV methylprednisolone prior to oral pred Should be a dramatic response

What need to give along steroids in GCA

Bisphosphonates due to long course of steroids Low dose aspirin

Complications of GCA

Visual loss - anterior ischaemic optic neuropathy Ocular comps eg retinal artery occlusion, diplopia, ptosis Stroke Aortic aneurysm and dissection Large cessel involvement - axillary, vertebral, SC, cranial -> limb claduaication, ishcaemia, vertebrobasilar insufficiency PMR Systemic symptoms

Long term steroids use risks

Osteoporosis Diabteets HPTN Increased infection susceptibility