Dr. S. BhalaraDr. S. BhalaraRheumatology unit Rheumatology unit West Herts Trust West Herts Trust
Cause? Not a muscle disease (despite the name)
CapsulitisCapsulitis synovitis/bursitis - Imaging/histology
Synovitis, tenosynovitis and oedema in hands and feet
VasculitisVasculitis Subclinical vasculitis of temporal arteries seen Vascular production of inflammatory mediators – IL-1, TGF-
B, IL-2 (even without cellular infiltrate) Circulating activated macropages/monocytes
Often very acute onset
Bilateral (symmetrical)
Pains may be widespread but proximal limb girdle predilection
Chest wall symptoms
Morning stiffness /systemic symptoms
Synovitis – seronegative arthritis often seen
Late onset rheumatoid arthritis – PMR very common presenting feature Gonzalez J Rheumatol 2000;27:2179
Inflammatory oedema –
RS3PE
ESR, CRP, IL-6
Normochromic, normocytic anaemia Reactive thrombocytosis
Liver enzymes (esp alk phos)
ESR < 40mm/hr in 7-22%Helfgott Arthritis Rheum 1996;39(2):304Gonzalez Arch Int Med 1997; 157(3):317
Gabriel J Rheumatol 1999;26(6):1333
? CRP more reliable Steroid trial (10-20mg for 1-2 weeks)
Malignancy Paraneoplastic musculoskeletal syndrome Metastatic disease Myeloma
Fibromyalgia
Vitamin D deficiency
Hypothyroidism
Cervical and lumbar spondylosis/spinal stenosis Bursitis/tendonitis
Steroids 15-20mg prednisolone
maintain 2-4 weeks after resolution of symptoms Taper by 10% every 2-4 weeks Once below 10mg/day by approx 1mg/month
Benign diagnosis – adjust according to symptoms – ESR/CRP guides but does not dictate therapy
Steroid sparing drugs 20% steroid resistant (must exclude paraneoplastic syndrome
or CTD/RA) Methotrexate Caporali Ann Int Med
2004;141:568 azathioprine/mycophenolate/leflunomide NSAID therapy alone is acceptable
No increase in mortalitySurvival in 315 PMR patients longer than controls Myklebust et al Scand J Rheumatol 2003;32::38
Use steroids/immunosuppresants with caution
Recurrence rate approx 20%
PMR causes increased bone turnover in it’s own right – Osteoporosis prophylaxis
Suspected GCA
Primary carePrimary care start high dose steroidsstart high dose steroids
visual symptoms
Secondary care Secondary care AAU urgent OPD
ReviewReview Opthalmology acute medicine Rheumatology Opthalmology acute medicine Rheumatology Neurology COENeurology COE
TA Biopsy TA Biopsy Opthalmology Gen surgeons Vascular surgeons
Follow up and Follow up and Opthalmology Rheumatology COE General Med Neurology
steroid tapersteroid taper
GPGP
Dr Hannah Cowling GP Watford
Dr S Bhalara Consultant Rheumatologist West Herts NHS Trust
Temporal Headache (localised )Scalp Tenderness (over temporal artery)Jaw ClaudicationTransient Visual DisturbancePolymyalgia RheumaticaMalaiseAnorexiaFeverESR >50Age >50 If four or more of the above symptoms/signs are present (must include 3 of those marked in bold) indicates high suspicion of Temporal Arteritis
Visual Symptoms
Prednisolone 1mg/kg 60-80mg dailySame Day referral to opthalmologistAspirin +PPIStart Bone Protection (eg Alendronate)Consider Amphotericin Lozenges
Later onset signs and less frequent presentations Ishaemic Optic NeuropathyThickened Temporal ArteryCentral Retinal Artery Occlusion3rd, 4th, 6th Nerve PalsiesArthralgiaIntracerebral Artery InvolvementAngina or Myocardial Infarction
Refer Urgently for Temporal Artery Biopsy
Please Fax a referral letter, marked ‘For Temporal Artery Biopsy’ to: Mr R Awad , Vascular Surgeon, Watford General Hospital, Fax – 01923Please state date of starting steroids as biopsy should be done within 2 weeks.
No Visual Symptoms
Prednisolone 40-60mg dailyPPI Start Bone Protection (eg Alendronate)Consider Amphotericin Lozenges
Remember Bone Protection should continue for 6 months after stopping steroids
Bolland et al BMJ Meta-analysis of of 11 RCTS
12000 – healthy postmenopausal women Ca supps > 500mg/day
hazard ratio for non fatal MI
= 1.31 (95% CI 1.02-1.67) (ie 30% increase)
CaveatsMI not a primary or secondary end point in any studyCA+ Vit D not analysedNo increase in MI mortalityNo increase in other cardiovascular events eg strokes
Those on calcium and vitamin D – no change
Calcium alone + coronary risk factors/past history of IHD Review need for calcium and either stop or replace with calcium and
vitamin D. Assess dietary intake of Calcium and give dietary advice
New osteopenic/osteoporotic patients
no change in practice but if dietary intake likely to be good check daily intake formally with diet chart as it may be possible to
withhold supplementation.
Search for and treat Vitamin D deficiency aggressively (this
will improve dietary calcium absorption).
aseptic necrosis of jaw, atypical femoral neck fractures, Oesophageal Ca, only occur with prolonged therapy
Schwartz et al J Bone Min Res 2007;22:S1057
ALN 10 years continuously Vs 5 yrs on then 5 yrs off Dexa at year 5 :- Rel risk of fracture in continued
group vs discontinued group (at year 10)
Fem neck T score ≤ -2.5 0.5 (0.26-0.96)
Fem neck T score ≥ -2.0 1.41 (0.75-2.66)