polymyalgia rheumatica a micro-teach of bsr & bhpr guidelines
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Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines. HDR Wednesday 23 rd November 2011 By Dr Mahya Mirfattahi GP Registrar. Core inclusion criteria. Age >50 years, duration >2 weeks Bilateral shoulder or pelvic girdle aching, or both Morning stiffness duration of >45mins - PowerPoint PPT PresentationTRANSCRIPT
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Polymyalgia Rheumatica
A micro-teach of BSR & BHPR guidelines
HDR Wednesday 23rd November 2011
By Dr Mahya Mirfattahi GP Registrar
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Core inclusion criteriaO Age >50 years, duration >2 weeksO Bilateral shoulder or pelvic girdle
aching, or bothO Morning stiffness duration of
>45minsO Evidence of an acute-phase response
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PMR O Can be diagnosed with normal
inflammatory markers, if O classical clinical pictureO Response to steroidsO Should be referred for specialist
assessment
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Core exclusion criteriaO Active infectionO Active cancerO Active GCAO Presence of following decreases probability
of PMR, therefore should be excludedO Other inflammatory rheumatic conditionsO Drug-induced myalgiaO Chronic pain syndromesO Endocrine diseaseO Neurological conditions e.g. Parkinsons
disease
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Assess for evidence of GCA
O Abrupt-headache (temporal) and usually with temporal tenderness
O Visual disturbance, including diplopiaO Jaw or tongue claudicationO Prominence, beading or diminished
pulse on examination of temporal artery
O Upper cranial nerve palsiesO Limb claudication or other evidence of
large-vessel involvement
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Recommended baseline investigations
O FBCO ESR/CRPO U&E, LFT, Calcium, CK, TSHO Protein electrophoresis & BJPO RF (ANA & anti-CCP may be
considered)O Dipstick urineO CXR
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Early specialist referral O Age <60 yearsO Chronic onset >2 monthsO Lack of shoulder involvementO Lack of inflammatory stiffnessO Prominent systemic features weight loss, night
pain, neurological signsO Features of other rheumatic diseaseO Normal of extremely high acute-phase
responseO Management dilemmas
O Poor response to treatment, needing treatment >2 years, relapses, corticosteroid contraindicated or not tolerated
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Treatment O Low-dose steroidO Suggested regimen
O Daily prednisolone 15mg for 3 weeksO Then 12.5mg for 3 weeksO Then 10mg for 4-6 weeksO Then reduce by 1mg every 4-8 weeks
O Alternative is methylprednisoloneO Milder cases or steroid-related complicationsO Initial dose 120mg every 3-4 weeks,
reducing by 20mg every 2-3 monthsO Usually 1-2 years of treatment needed
O If >2 years refer
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Recommended use of bone protection
O Individual with high fracture risk e.g. aged >65 years or prior fragility fractureO Bisphosphonate with calcium and vitamin
DO DEXA not needed
O Other individualsO Calcium and vitamin D supplementation
when starting steroid therapyO DEXA scan recommendedO A bone-sparing agent if T-score <-1.5
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MonitoringO Follow up schedule
O Weeks 0,1-3, 6O Months 3,6,9, 12 in first year
O At each visit assessO Response to treatment: proximal pain,
fatigue and morning stiffnessO Complications of disease including symptoms
of GCAO Steroid-related adverse effectsO Atypical features or those suggesting an
alternative diagnosisO FBC, ESR/CRP, U&E, glucoseO Usually 1-3 years of treatment
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RelapsesO Not just rise in ESR/CRPO Clinical features of GCA: treat as GCA
(40-60mg prednisolone & urgent referral)O Clinicial features of PMR: increase
prednisolone to previous higher doseO Single IM injection of methylprednisolone
can also be usedO Further relapses: DMARD after 2 relapses