Fichas
PMR and TA
Fichas del conjunto (20)
- 1What percentage of >65 year olds have PMR?3%
- 2A) What percentage of PMR patients get TA? B) What percentage of TA patients get PMR?A) 15-30%
B) 50% - 3What is the pathophysiology of PMR?Mild, non-erosive synovial and peri-articular inflammation of proximal joints
Some patients: sub-clinical vasculitis - 4What is the pathophysiology of TA?Granulomatous vasculitis
As a result of accumulation of inflammatory infiltrate in medium and large arteries
Causes vessel wall injury, luminar occlusion and vascular stenosis = ischaemia - 5What are the diagnostic criteria for PMR?>50yo
Duration >2 weeks
Bilateral pelvic and/or shoulder girdle ache
Morning stiffness lasting >45 minutes
Evidence of an acute phase response (ESR/CRP/ALP)
And don't forget to assess for TA! - 6What are some differentials for proximal girdle pain?Rheumatoid arthritis
Late onset spondyloarthritis
Connective tissue disease (SLE)
CPPD (Pseudogout)
Muscle disease: myositis, dermatomyositis, polymyositis
MSK problem: bursitis, tendinitis
Cervical spondylosis
Neoplasm: myeloma, leukaemia, paraneoplastic syndrome
Endocrine: Hypothyroidism, hypercalcaemia, hyperparathyroidism, T2DM
Atypical presentation of Parkinson's
Osteomalacia
Infection: flu; septic arthritis/osteomyelitis; TB
Fibromyalgia syndrome - 7SIDEBAR: Which drugs especially can cause myositis?Statins
- 8What investigations should be done in proximal girdle pain?Bloods: ESR/CRP, FBC, U+E, glucose, calcium (PTH if abnormal), TFTs, ANA, RF, anti-CCP, CK
Chest x-ray
Urine dip - 9What results would you expect from investigating PMR?Raised ESR/CRP
Normochromic/normocytic anaemia (anaemia of chronic disease)
Platelets may be raised
RF, ANA and anti-CCP would all be negative - 10Which imaging investigations would be useful in suspected PMR?MRI
Ultrasound
To show peri-articular inflammation - 11What is the management of PMR?15mg prednisolone for 2 weeks (patients should report a 70% improvement; refer to specialist if patient is <60, there are red flags, there is no response to steroid, it is an atypical presentation etc)
- 12What is the initial dose of prednisolone for PMR and what is the regime for reducing it to a maintenance dose?10-20mg for 1 month
Reduce to 10mg by 2.5mg every 2-4 weeks
Reduce by 1mg every 4-6 weeks (or until symptoms return) - 13What is the maintenance dose of prednisolone for PMR most people get stuck at and what is the regime for withdrawal?5-7mg/day for 6 months
Final reduction by 1mg every 6-8 weeks - 14How long is the treatment course for PMR?2 years
(But a lot of people take 3) - 15Which drugs can be used as steroid-sparing agents in PMR?Methotrexate
Azathioprine - 16What are the symptoms of temporal arteritis?(Unilateral, constant) Headache
Scalp tenderness
Altered vision (15%)
Jaw or tongue claudication (50%)
Nodular swellings
Poor pulsation
RARE = scalp necrosis, cranial nerve palsy, limb claudication, systemic signs or symptoms - 17How is TA picked up?History and examination - palpate the temporal arteries
Bloods: raised ESR/CRP
raised platelets and WCC
anaemia
? raised ALP
Temporal artery biopsy is the gold standard diagnostic tool. (50% false negative rate due to skip lesions) - 18What lesion is characteristic of TA on US?Halo sign
- 19What is the management of TA A) without visual symptoms B) with visual symptoms?A) Prednisolone 20-40mg daily for 8 weeks. Reduce by 5mg every 3-4 weeks
At 10mg, treat as PMR
B) Prednisolone 40-80mg daily for 8 weeks. Reduce to 20mg daily over 4 weeks. Treat as uncomplicated TA - 20A) How long are steroids weaned in TA? B) What is the threshold for using steroid-sparing drugs?A) 1 year-18 months
B) Low
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- Rheumatology teaching
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- esther.westwood
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