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Treatment options when patient complains of morning stiffness
You haven't seen Mrs Smith for a few months and you are shocked to see her walk in and sit down as if she were an old woman instead of 62 years old. She tells you she has been gradually slowing down and now struggles to get out a chair. She feels exhausted and is full of aches and pains; she is so stiff she finds it almost impossible to fasten her bra strap or brush her hair in the mornings.
Dr Melanie Wynne-Jones discusses.
What is the significance of the stiffness?
Morning stiffness more than a few minutes after getting up is a sign of inflammation. It is found in a number of conditions including localised joint problems, connective tissue disorders, hypothyroidism, Parkinson's disease and myositis/myopathies, including drug induced such as statins.
The clue here is the pronounced limb girdle stiffness which is typical of polymyalgia rheumatica (PMR). It affects the neck, shoulders and hips bilaterally and symmetrically, lasting an hour or more after waking.
PMR comes on gradually over a few weeks or months, and the patient may virtually seize up. There may be associated symptoms such as muscle tenderness, fatigue, weight loss, night sweats and depression, or peripheral symptoms such as carpal tunnel syndrome, tenosynovitis or inflamed joints.
Symptoms may initially be blamed on arthritis in the shoulders or neck, and malignancies, including multiple myeloma, occasionally present with PMR-like symptoms.
How is PMR diagnosed?
PMR usally starts after the age of 60 but strikes some people in their 40s. It affects three times more women than men, and seven times more black people than white.
The incidence may be as high as 30-50/ 100,000 per year in the elderly people. The diagnosis can often be made from the history. Supporting investigations include:
·ESR usually markedly raised, but may be normal at presentation in up to a fifth of sufferers
·CRP (C-reactive protein) is usually raised
·Full blood count (there may be a mild normocytic normochromic anaemia and slightly raised neutrophil count)
·Blood tests, X-rays or scans to rule out other causes (for example, thyroid function tests, creatine kinase, protein electrophoresis, chest
X-ray). Although PMR can be managed in primary care, referral may be needed where the diagnosis is in doubt.
How does temporal arteritis fit in?
Giant cell arteritis (GCA) occurs in up to one in 20 patients with PMR at some stage and can affect any artery. The temporal artery is most commonly affected, producing unilateral tenderness, headache and reduced pulsation; this may progress to blurred vision and visual loss if not treated urgently with 40-60mg prednisolone daily.
There may also be jaw claudication, hemiparesis, peripheral neuropathy, deafness, depression or confusion.
Although temporal arteritis may be diagnosed by urgent biopsy, skip lesions can occur; if you suspect the condition, make an urgent ophthalmological referral or telephone for advice.
Should you treat PMR on suspicion?
Blood results do not usually take long, and if you do not suspect GCA, another few days will not harm the patient.
A trial of steroids may confuse the issue but please the patient by improving symptoms caused by other conditions.
Steroid treatment, however, produces a dramatic improvement in PMR within a few days; patients are usually delighted.
Start with 15mg daily for about four weeks; the dose can then be titrated down by 2.5mg every two weeks to 10mg, while observing the patient and the ESR/CRP, and then by 1mg every six weeks to 5-7mg daily. Patients should be reviewed regularly to minimise steroid exposure.
If the patient's response does not equate with the inflammatory markers you may need to treat the patient rather than the blood test. But if the inflammatory markers do not come down after a couple of weeks' treatment, you may need to reconsider alternative diagnoses (see above) or referral. Some rheumatologists believe all patients with PMR should be referred for assessment. The Arthritis Research Campaign is conducting a study aimed at defining referral criteria.
How should we advise patients about steroids?
Before prescribing, patients should be:
·Told about the diagnosis and why steroids are needed.
·Counselled about the side-effects up to three-quarters of people on long-term steroid treatment may develop osteoporosis, weight gain, hypertension, peptic ulceration, depression, glaucoma, cataract, skin fragility or impaired glucose tolerance (blood sugar monitoring may be appropriate in some patients).
·Warned about immunosuppression and advised to have flu and anti-pnemococcal jabs.
·Asked whether they have had chickenpox (check varicella antibodies if in doubt and advise patients at risk to report immediately any contact with chickenpox or shingles as they will need immunoglobulin/antivirals).
·Told not to stop taking their steroids suddenly, and to carry a steroid card at all times.
·Advised on osteoporosis prevention and prescribed calcium, vitamin D or bisphosphonates and/or referred for bone densitrometry/specialist opinion as appropriate.
·Polymyalgia rheumatica should be suspected when limb girdle stiffness is pronounced, but has a wide differential diagnosis and should be fully investigated
·15mg prednisolone should produce a dramatic response within days
·Steroid treatment may be needed for several years and should be adjusted according to patient response/inflammatory markers
·Patients should be actively managed to minimise osteoporosis; weight gain, blood pressure and blood sugar should also be monitored
·Refer urgently if you suspect giant cell arteritis which may develop at any time during PMR
1 PRODIGY Guidance on Polymyalgia Rheumatica and Giant Cell Arteritis www.prodigy.nhs.uk/guidance.
2 Glucocorticoid-induced osteoporosis. Guidelines for prevention and treatment. The Bone and Tooth Society
of Great Britain, The National Osteoporosis Society and the Royal College of Physicians. (December 2002). www.nos.org.uk/PDF/Glucocorticoid.pdf
3 Hands On Guide to PMR for GPs Arthritis Research Campaign head office on 01246 558033
4 Patient Information Leaflet on PMR Arthritis Research Campaign, Copeman House, St Mary's Court, St Mary's Gate, Chesterfield, Derbyshire S41 7TD
0870 850 5000 www.arc.org.uk/about_arth/
Melanie Wynne-Jones is a GP in Marple, Cheshire