Polymyalgia Rheumatica

Question 1

What is PMR and how does it present?

What are some of the systemic signs?

Answer 1

-Rheumatic conditions, affects the shoulder and hip girdles, secondary to low grade synovitis

FEATURES:
Early morning stiffness, symmetrical.

Pain can involve neck, upper arms, lower back and thigshs.

Other areas affected:
Carpel Tunnel Syndrome
Non erosive asymmetrical peripheral arthritis (knees and small joints of hands and knees)

2/Fever, depression, fatigue, anorexia and weight loss in 40% of patients.

(ref: RACGP article PMR diagnosis and mangement)

Question 2

Giant Cell Arteritis is associated with PMR, when would you investigate for it?

Answer 2

New headache or unexplanied pain above the neck, high inflammatory markers.

Question 3

What is the diagnostic criteria for PMR?

Answer 3

Age ≥50 years with new bilateral shoulder pain

New hip involvement (pain, tenderness, limited movement)
Morning stiffness for >45 min
Other joints other than hip & shoulder not involved
Elevated C-reactive protein and/or ESR
Rh and Anti CCP negative

(ref etg & RACGP article PMR diagnosis and mangement)

Question 4

Investigations for PMR?

Answer 4

FBC, UEC, LFT’s, CMP
ESR, CRP
Protein Electrophoresis (multiple myelom)
TSH
Creatinine Kinase
Rheumatoid factor (consider ANA, Anti-CCP)
Dipstick urinanalysis

(ref: RACGP article PMR diagnosis and mangement)

Question 5

Conditions that mimic PMR?

Answer 5

Vascular - Giant Cell Arteritis 
Infection  
Neoplasm - MM, lymphoma, leukemia 
Drugs induced - statin myopathy 
Endocrine - hypothyroidism 

Rheumatic disease

• late onset spondyloarthropathy, rheumatoid arthritis
• SLE or connective tissue disorder
• polymyositis
• fibromyalgia
• pseudogout

Chronic pain syndrome
local hip or shoulder pathology

(ref: RACGP article PMR diagnosis and mangement)

Question 6

1/ Management

Answer 6

1/ low dose steroid therapy (can start at 15mg / day for eg.) Treatments usually req’d for 12 months (Ref:etg)
(ref: RACGP article PMR diagnosis and mangement)

Question 7

What % of patients with PMR will also have GCA?

Answer 7

15%

Ref Etg

Question 8

What are the side effects of corticosteroids?

Answer 8

• Increased risk of infection

Endocrine
• Cushing syndrome
Osteoporosis

MSK
• Weight gain

Dermatology
• Skin bruising

Cardiac
• Raised blood pressure
• Impaired blood glucose
• Cardiac failure

Psychological
• Depression

Eyes
• Cataracts
• Glaucoma

(ref: RACGP article PMR diagnosis and mangement)

Question 9

What is the diagnostic criteria of GCA?

Answer 9

Age >50 years
New onset of localised headache
Temporal artery tenderness or
decreased temporal artery pulse
ESR ≥50 mm/hr
Positive temporal artery biopsy

(PMR a clinical update, racgp 2014)