"Polymyalgia Rheumatica and Giant Cell Arteritis" (My Synopsis)

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 
Am Fam Physician. 2006 Nov 1;74(9):1547-1554.

     Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are two diseases that are often seen together. CGA is it most common vasculitis in adults, and PMR is the most most common inflammatory disease in adults. It is important to know the GCA is an inflammation in medium to large arteries. PMR causes muscle and joint pain in the proximal muscles (hip, neck and shoulders). Occasionally there is also pitting edema, distal joint pain, and systemic symptoms. The core criteria for PMR includes; age over 50 years old, aching proximal muscles, symptoms lasting two weeks, morning stiffness of the girdle muscles for 45 minutes, and elevated ESR or CRP. A normal ESR can be estimated by using this formula (age/2 for men; for women is age/2 plus 5). The ESR in PMR is usually above 40 mm/hr. An ESR above 100mm/hr would occur in a patient with PMR and GCA.  Other lab work to order in PMR is a CBC, CK, thyroid, BMP, RF, UA, and SPEP. A chest x ray can help rule out cancer causing paraneoplastic syndrome. Treatment consists of corticosteroids with a slow taper. The treatment will last an average of 1.8 years. Older women with higher ESR may be at more risk for relapse or GCA. Patients with recurrent relapses or who cant tolerate a slow taper should be referred to a specialist. A that point, a rheumatologist may consider using a DMARD. Patients on long term steroids may need bisphosphonates, alendronate, vitamin D and calcium, or another type of prophylaxis to maintain bone density. 
     CGA can affect any medium or large artery, including the extracranial carotids, the temporal artery, or the thoracic aorta. The disease presents as a new onset temporal headache, fatigue, anorexia, or weight loss.  There may also be scalp tenderness. Jaw claudication or vision problems (diplopia, blurry vision) are signs of ischemia. Patients over 50 years old with signs and symptoms should be treated immediately to avoid progression to blindness. An elevated ESR (>50mm/hr) or CRP is another sign to have urgent treatment.  Diagnosis is made by temporal artery biopsy. The exact spot of the vasculitis should be identified on the patient's skin because taking a biopsy of an unaffected part (skip lesions) will lead to negative results. The sample should be at least 1 cm. A negative biopsy in a patient with strong clinical indication for disease may prompt a contralateral biopsy. Ultrasound may aid in performing the biopsy. After the initial treatment is started, a referral to a rheumatologist is warranted. Methotrexate is another treatment option. Treatment last for about three months. The patient will have to be monitored for a thoracic aneurysm every two years by x ray. Patients on long term steroids will need osteoporosis prophylaxis.