A Brief Synopsis of AFPs "Polymyalgia Rheumatica and Giant Cell Arteritis"

Polymyalgia Rheumatica and Giant Cell Arteritis
BRIAN UNWIN, COL, MC, USA, CYNTHIA M. WILLIAMS, CAPT (R), MC, USN, and
WILLIAM GILLILAND, COL, MC, USA, Uniformed Services University of the Health Sciences, Bethesda, Maryland
http://www.aafp.org/afp/2006/1101/p1547.pdf
Am Fam Physician. 2006 Nov 1;74(9):1547-1554.

     Giant cell arteritis (CGA) and polymyalgia rheumatica (PMR) are very similar inflammatory vascular disorders and oftentimes, patients end up with both. CGA usually presents with temporal pain, headache and vision problems. PMR presents with pain and stiffness in the girdle (hip and shoulder) muscles. Both are more common in patients over 50 years old.      Findings associated with PMR include age over 50 years, ESR above 50 mm/hr, mild anemia, pain with morning stiffness of the proximal muscles, and inflammatory symptoms (fever, night sweats, weight loss, anorexia, and depression). Other symptoms include asymmetric wrist and knee arthritis, hand and feet swelling, carpal tunnel syndrome, shoulder/ hip bursitis, and extremity tenderness.      Findings associated with GCA include age over 50 years, ESR above 50 mm/hr, anemia, headache, jaw claudication, PMR, arthralgia, visual problems,  inflammatory symptoms, and an abnormal temporal artery. The patient may present with a low grade fever and a red, tender, thickened, nodular, or pulseless temporal artery. A detailed vision exam, joint exam, and temporal artery biopsy should be considered.  Steroid treatment should not be delayed in lieu of lab work or biopsy. Ultrasound may help determine the best section of the artery for biopsy.      The differential diagnosis for GCA and PMR includes fibromyalgia, multiple myeloma, OA, RA, and polymyositis. A negative ESR will usually rule out CGA (and PMR). Corticosteroid use will give a falsely low ESR.  A rough estimate of a normal ESR is the patients age divided by 2 (then add 5 if it is a woman). Other lab abnormalities include elevated CRP, thrombocytopenia, elevated LFTs, and microscopic hematuria.     Treatment consists or prednisone. PMR requires low dose steroids for 2-4 week after the disease symptoms resolve, followed by a slow taper (lower the dose by 1 mg/day each week).  A disease activity score has been developed for PMR to help monitor and adjust therapy. The five variables are;A visual analog pain scaleA visual analog scale for the physician's assessmentCRPLength of time with morning stiffnessAbility to elevate armsA score less than 7 suggests low disease activity, 7-17 is medium disease activity, and above 17 is high activity.     GCA requires high dose intravenous steroid treatment. The treatment will not affect the quality of the temporal artery biopsy. It is useful in preventing permanent blindness, reduce fever, headache, and myalgia. Treatment can be tapered after 6 months, and should last 2-3 years. The treatment dose can be increased if a flareup or relapse occurs.      Excessive steriod therapy may lead to side effects including osteoporosis, myopathy, bruising. hypertension, elevated cholesterol, diabetes, insomnia, restlessness, hypomania, and depression.  The osteoporosis can be treated with vitamin D. calcium, weight bearing exercises, and bisphosphonates. Antidepressants can be used for emotional issues, while avoiding hypnotics and benzos. Hypertension may be due to subclinical vasculitis and may be assessed by comparing upper and lower extremity blood pressures.