Polymyalgia Rheumatica

Question 1

What is polymyalgia rheumatica?

Answer 1

Common clinical syndrome characterised by pain and stiffness in neck, shoulder and pelvic girdle

Question 2

At what age does the onset of polymyalgia rheumatica almost always occur, and what does this indicate about prevalence and incidence amongst different populations?

Answer 2

Onset occurs almost always aged 50 and over

Highest prevalence and incidence in middle-aged and elderly populations

Question 3

What is the mean age of onset of PMR?

Answer 3

70

Question 4

In PMR, describe the presentation of muscle stiffness?

Answer 4

Bilateral and symmetrical

Question 5

In PMR, describe the presentation of pain throughout body?

Answer 5

Diffuse/widespread pain

Question 6

In PMR, does the muscle stiffness remain constant throughout the day?

Answer 6

No, EMS lasts several hours

Question 7

What is the relationship between GCA and PMR?

Answer 7

They often coexist, so are probably the same disease

Question 8

If a patient has PMR and GCA, what does this indicate about their presenting symptoms?

Answer 8

They will also present symptoms seen in GCA, such as ocular disturbances

Question 9

Give 5 systemic features of PMR?

Answer 9

Loss of appetite
Weight loss
Low grade fever
Malaise
Fatigue

Question 10

What is PUO, and why can PMR be mistaken for this condition?

Answer 10

Pyrexia of Unknown Origin: Temperature greater than 38.3℃ on several occasions, that is accompanied by more than 3 weeks of illness

PMR is mistaken for PUO due to systemic features

Question 11

Give 3 findings of physical examinations, in patients with PMR?

Answer 11

limited range of movement in shoulder, cervical spine, hips

motor function is normal

no muscle damage or tenderness

Question 12

Give 2 findings of lab investigations of PMR?

Answer 12

Normal CPK/CK level which indicates that there is no muscle involvement/damage

elevated CRP and ESR levels

Question 13

In PMR management, what is the initial dose of prednisolone and how is it determined?

Answer 13

Prednisolone started at 15-20 mg dose that is tailored to individual’s weight, symptom severity, comorbidities

Question 14

In PMR, what steroid starting agent is usually given?

Answer 14

MTX

Question 15

What is a steroid sparing agent?

Answer 15

additional drug that is administered so that steroid dose can be kept as low as possible

Question 16

How should the prednisolone dose be tapered in PMR management, and what is the duration of this process?

Answer 16

Tapered slowly until minimum dose is reached, at which individual is still symptom free

Monitor symptoms and ESR level, to taper dose with aim of reaching 10-15 mg dose by 8 weeks

Question 17

If a PMR relapse/flare occurs whilst the prednisolone dose is being tapered, how it this managed?

Answer 17

Increasing steroid dose by 10-20% or until symptoms are managed, then attempt to taper dose again in a few weeks

Question 18

After the prednisolone dose has been adjusted to 10-15 mg, how is it further tapered in PMR management?

Answer 18

rate of reduction should decrease by 1 mg per month

Question 19

What is the overall duration that most PMR patients need glucocorticoids for?

Answer 19

12-24 months (up to 2 years)

Question 20

If PMR coexists with GCA in a patient, how does this affect the initial prednisolone dose?

Answer 20

Use higher dosage of prednisolone to prevent complete blindness, as this is a medical emergency

Question 21

What medication is taken after assessing osteoporosis risk and vitamin D deficiency?

Answer 21

Bisphosphonates

Question 22

Can tocilizumab be used for PMR cases?

Answer 22

Tocilizumab commissioned for resistant/refractory cases associated with GCA for 12 months use