10. Polymyalgia Rheumatica & Giant Cell Arteritis

2nd MC inflammatory rheumatic disease (after RA) in age >50

Polymyalgia rheumatica

Polymyalgia rheumatica

Systemic inflammatory disorder

Demographic associated with polymyalgia rheumatica

- Female age >50

- Northern European descent

S/S & PE of polymyalgia rheumatica

- Symmetric, shoulder / pelvic (proximal) girdle pain → Decreased ROM

- AM stiffness >45 mins

- Nonerosive arthritis of knees & wrists → Diffuse swelling of distal extremities, if untreated

- NO proximal joint swellin

- NO true muscle weakness

- NO temporal artery abnormalities (overlap abnormal)

**Mimics RA if untreated

What 5 differential diagnoses mimickers of polymyalgia rheumatica must be ruled out? (include in diagnostic workup)

- RA (+ RF & anti-CCP)

- GCA / TA (elevated ESR)

- Malignancy

- Myositis (CK, aldolase)

- Hypothyroidism

Additionally: Hep C, LFTs, ESR & CRP, serum protein electrophoresis (SPEP)

What does serum protein electrophoresis (SPEP) screen for?

Monoclonal gammopathy — Myeloma, amyloidosis, hematologic malignancy w/ diffuse myalgias

What diagnostic finding on labs makes polymyalgia rheumatica very unlikely?

Normal ESR & CRP → Referral

**High clinical suspicion with normal levels → MSK US for local pathology

What level of ESR is indicative of polymyalgia rheumatica?

>40 mm/h

What is always elevated with untreated polymyalgia rheumatica?

CRP

**Always order ESR & CRP together!

What is the best pharmaceutical management for polymyalgia rheumatica?

Low-dose steroids — Prednisone 12.5-25mg or less

- 1 year for patients <70, longer if oolder

- Dose based on S/S & ESR/CRP

ADRs to monitor with steroid use for management of polymyalgia rheumatica

- Glaucoma / cataracts — Ophthalmology referral

- Osteoporosis — BMD, add calcium & vitamin D, bisphosphonate

- Monitor glucose & A1C, BP & weight

What medication is indicated for patients that cannot tolerate a steroid taper for relapsing polymyalgia rheumatica?

Sarilumab / Kevzara

What condition can commonly overlaps with polymyalgia rheumatica?

Giant cell arteritis

**MUST monitor for development; DO NOT MISS

PE exam for patients that f/u with polymyalgia rheumatica that can indicate GCA

Unequal BP between extremities, bruits, new murmur of aortic insufficiency

MC systemic vasculitis

Giant cell arteritis

Giant cell arteritis

Inflammatory disease of medium & large sized vessels

Pathophysiology of giant cell arteritis

Granulomatous inflammation with multinucleatd giant cells — Inflammation → Luminal narrowing

Demographic associated with giant cell arteritis

- Women age 74

- Caucasian & Scandinavian descent

MC arteries affected with giant cell arteritis

- Extracranial branches of carotid

- Primary branch arteries of aorta

S/S of giant cell arteritis

- Jaw claudication (arterial obstruction)

- New onset HA

- Visual disturbances

- Scalp tenderness

- Constitutional S/S — Weight loss, etc.

**5 MC; Document at each visit

PE findings with giant cell arteritis

- Positive tap tenderness

- Asymmetric BPs

- Bruit over TA

- Pain open & closing jaw

Red flag symptoms with giant cell arteritis

- Amaurosis fugax — Transient loss of vision

- Field cuts

- Blue vision — blue tint d/t ischemia

- Double vision

Complications of giant cell arteritis

- VISION LOSS

- Stroke — Associated with vertebral artery involvement

- Aortic aneurysm & dissection

Diagnostic workup of giant cell arteritis

- Marked elevated ESR

- C-reactive protein

- Thrombocytosis

- Elevated alkaline phosphatase

- Imaging for large vessel involvement

- Temporal artery biopsy — Definitive

Management of giant cell arteritis

- HIGH-DOSE PREDISONE (60 mg/day) & ASAP referral

Monitoring with giant cell arteritis

- Annual for aneurysm

- Murmur of aortic insufficiency

- Bruits — Carotid, temporal A.

- Unequal extremity BP