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)