Polymyalgia Rheumatica

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Polymyalgia Rheumatica

• Sanjeev Patel
• Consultant Physician
• Senior Lecturer in Rheumatology

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PMR

• How many of you have diagnosed and treated a
  patient with PMR in the last year?
• What is PMR?
• Muscle disease (myositis?)
• Inflammatory arthritis
• Vasculitis
• Dont know (but it goes away with steroids)

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What is PMR?

• Autoimmune inflammatory disease
• Aetiology unknown
• Genetic predisposition
• Usually after the age of 50 yrs old
• Women more than men

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Epidemiology

• Incidence increases with age
• Peak at 70 to 80 years
• 31 female to male ratio
• Incidence 13 to 68 per 100 000 pop
• Prevalence is 700 per 100 000 pop

Lawrence et al Arthritis Rheum1998 41778 -99
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How to diagnose PMR?

• Clinical diagnosis so depends purely on clinical
  judgement
• Therefore large variation
• Number of criteria used in research but limited
  use in clinical practice
• E.g. Chuang criteria 1982

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Features of PMR

• Clinical syndrome
• 50 years of age
• gt 2 weeks of bilateral shoulder and / or pelvic
  aching
• Morning stiffness of 45 minutes
• Acute phase reaction

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Features of PMR

• Musculoskeletal symptoms
• Stiffness
• Usually predominates
• Worse after rest and in the morning
• Pain
• Usually diffuse and often worse at night
• Muscle strength is normal
• There is no evidence for myositis

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Features of PMR

• Musculoskeletal symptoms
• Pain and stiffness
• There is no evidence for myositis
• There is evidence of proximal joint inflammation
• Peripheral joints can also be inflamed
• Often turns out to be seronegative RA

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What is PMR?

• PMR and GCA are different phases of the same
  disease ?

GCA
PMR
Alestig Barr Lancet 1963
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What is PMR?

• 10 to 15 of patients with pure PMR symptoms
  have a positive temporal artery biopsy
• 30 pure PMR patients with negative TA biopsy
  have evidence of vasculitis in large vessels
  on PET scanning

GCA
PMR
Alestig Barr Lancet 1963
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What is PMR?
GCA
PMR
60 of patients with GCA have PMR symptoms
Alestig Barr Lancet 1963
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PMR at the tissue level

• Vasculitis
• Temporal artery biopsy
• Inflammation in proximal joints
• Synovial and periarticular tissues
• Shoulder synovitis, bursitis, capsulitis and
  biceps tendonitis

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Temporal artery biopsy
Biopsy showing fragmentation of internal elastic
lamina, with infiltration by histiocytes,
lymphocytes, epithelioid cells and
multinucleated giant cells, and accompanying
intimal proliferation occluding the lumen
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PMR and acute phase reaction

• Nearly all patients have acute phase reaction
  (ESR and CRP elevated)
• PMR with normal ESR is recognised

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ESR versus CRP

• ESR
• Erythrocyte sedimentation rate
• CRP
• C-reactive protein

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Acute phase reactionComparision of ESR and CRP

ESR Inexpensive, quick, simple to perform Affected by a variety of factors, including anemia and red blood cell size not sensitive enough for screening
CRP Most rapid response to inflammation (complementary to ESR in this regard) Wide reference range may necessitate sequential recording of values, expensive, batch processing may delay individual results
PV Unaffected by anemia or red blood cell size Expensive, not widely available, technically cumbersome to perform
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Draft guidelines for PMR
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BSR guidelines for PMR

• Inclusion / Exclusion criteria
• Response to steroids
• Investigations prior to treatment
• Evaluation of proximal pain and stiffness

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Treatment of PMR

• Steroid sensitive disease
• Prednisolone 10 to 15 mg per day
• Assess response at 2 weeks
• Should be substantially improved
• (See handouts)
• If poor response stop steroids and reconsider
  diagnosis or refer

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Outcomes following diagnosis of PMR

• Correct diagnosis
• Steroid withdrawal after 1 to 2 years
• However one third relapse and go on to have a
  more chronic relapsing course
• If incorrect diagnosis
• Common misdiagnosis?
• GOA
• Soft tissue diseases
• Cancers and other inflammatory states

Salvarani et al NEJM 2002347261-271
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Outcomes following diagnosis of PMR

• Steroid related complications
• Occur in about 65 of patients
• Type 2 DM
• Osteoporotic fractures
• Obesity
• Skin changes

Gabriel et al Arthritis Rheum 1997401873-8
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Monitoring of PMR

• Clinical assessment is vital
• Symptoms
• Stiffness or reduced ROM in shoulders
• ESR / CRP are supportive

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PMR resistant to steroids

• Other treatments are helpful
• Methotrexate
• Anti-TNF (rarely)
• Remember that other diseases can also occur and
  cause ESR to rise

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Who to refer
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Common clinical scenario

• Woman aged 70 with PMR diagnosed 3 years by
  previous GP
• Widespread aches on prednisolone 7.5mg/day
• Worse when steroids reduced
• ESR 55 mm/hr
• What do you do?

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Common clinical scenarios

• Need to decide whether symptoms are due to PMR or
  OA
• ESR will go down with steroids
• May be a non-specific effect
• Measuring CRP can help
• Best to have one clinician repeatedly assessing
  symptoms and ESR
• Treat symptoms with other drugs if you do not
  think they are related to PMR

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Common clinical scenarios

• If you think the patient has persistently active
  PMR despite steroids refer
• Review diagnosis
• Consider DMARDs