1 / 20

Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis

Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis. Dr Martin Lee MRCP(Rheum) Rheumatology Consultant, Honorary Senior Clinical Lecturer & Associate Clinical Sub Dean Freeman Hospital, Newcastle. PMR: Pitfalls. Are you sure the diagnosis is right?

leal
Télécharger la présentation

Rheumatology for GP Trainees: Polymyalgia Rheumatica & Giant Cell Arteritis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Rheumatology for GP Trainees:Polymyalgia Rheumatica & Giant Cell Arteritis Dr Martin Lee MRCP(Rheum) Rheumatology Consultant, Honorary Senior Clinical Lecturer & Associate Clinical Sub Dean Freeman Hospital, Newcastle

  2. PMR: Pitfalls • Are you sure the diagnosis is right? • Is the patient on the right treatment? • Steroids aren’t working? • Can’t get the steroid dose down? • Complications of the disease or treatment?

  3. PMR: Bird 1979 Diagnostic Criteria • 3 of the following must be present: • Bilateral shoulder pain or stiffness • Onset < 2 weeks • ESR > 40 • Morning stiffness > 1hr • Age >65 • Weight loss • Bilateral upper arm tenderness

  4. PMR • Epidemiology: • Average age onset 70, never <50 • Incidence in >50, 1/1,000 • Female 3:1 Male • Natural Progression • Self limiting (chronic relapsing), morbidity • Clinical Features • Bilateral/symmetrical shoulder/pelvic stiffness > pain • Morning stiffness >45minutes (and inactivity stiffness) • Systemic symptoms, association with GCA • Painful restriction active/passive movements • Not weakness (NB. pain and stiffness) • Does not involve distal joints • Inflammatory markers

  5. PMR: Management • Prednisolone 15mg (can escalate to 20mg) • If patient responds clinically and laboratory markers normalise then gradually taper steroid dose unless relapse occurs (clinical rather than laboratory) • 70% global clinical improvement after 1 week • Normal acute phase response after 3 weeks • 15mg 1/12, 12.5mg 1/12, 10mg 1/12 • Then reduce by 1mg/day every 4-6 weeks • 12 – 18 months

  6. Case History 1: Mrs KF • January 2010: • 82-year old female presented to GP • Buttock pain and weakness • Pain in shoulders • Diagnosed with PMR and started on steroid ?dose • October 2010: • Admitted via AMU • Upper back pain (not stiffness) and leg weakness • 3/12 weight loss and low appetite • CRP 336 • Prednisolone increased to 30mg due to ‘flare of PMR’ and referred to Rheumatology

  7. Case History 1: Mrs KF • Urinalysis blood 2+, protein 1+ • Vasculitis screen (cANCA 1:320, PR3 positive) • Renal biopsy: Limited Wegener’s granulomatosis • Prednisolone 100mg alt days, cyclophosphamide

  8. When is PMR not PMR? • Inflammatory conditions: • RA • Dermatomyositis / Polymyositis • Vasculitis • Late onset SpA (ie. AS, PsA)

  9. When is PMR not PMR? • Non-Inflammatory conditions: • OA • Rotator cuff disease • Adhesive capsulitis • Bursitis (ie. subacromial bursitis) /tendonitis • Spinal spondylosis • Hypothyroidism • Infection (ie. infectious endocarditis) • Malignancy (ie. lung / myeloma) • Paraneoplasia • Parkinsonism • Chronic pain syndrome / Fibromyalgia • Osteomalacia • Hypo / hypercalcaemia • Drug induced (statins)

  10. Bilateral shoulder OA and adhesive capsulitis

  11. Investigations • FBC • ESR/CRP/plasma viscosity • U&E • LFT • TSH • CK • Calcium, ALP • Protein electropheresis • RF • Urine Dipstick • ?ANA • ?Imaging (ie. CXR, shoulders)

  12. GCA: ACR 1990 Classification Criteria • 3 of the 5 criteria (sensitivity 94%, specificity 91%): • Age at onset ≥ 50 years • New headache • Temporal artery tenderness or loss of pulsation • ESR ≥ 50mm/hr • Abnormal temporal artery biopsy

  13. GCA: Temporal Artery Biopsy • A biopsy may not be required in all cases but can be helpful • Up to 6 weeks after treatment • Steroids should not be withheld • Positive in 70% of patients with GCA (20% of patients with PMR): • ?Diagnosis / alternative diagnosis • ?Diagnosis retrospectively • ?Initial steroid dose • Classification vs diagnostic criteria

  14. GCA: Ultrasound

  15. GCA: Management • In the absence of visual symptoms, immediately treat with 40-60mg prednisolone (40mg, 30mg, 20mg, 17.5mg, 15mg, 12.5mg, 10mg) • Visual symptoms (Ophthalmology, IV methylprednisolone) • Aspirin, bisphosphonates, calcium/vitamin D, PPI • Permanent visual loss 7-14% due to AION • Other complications include aortitis (15%)

  16. Royal College of Physicians. Glucocorticoid-induced osteoporosis: Guidelines for prevention and treatment Age 65 Age <65 Previous Fragility Fractures or incidental fragility fracture on treatment Investigations No Previous Fragility Fractures Measure BMD DXA T Score Hip ± Spine >0 0 to -1.5 -1.5 or lower TREAT General Measures General Measures Rpt DXA 1-3yrs

More Related