inflammatory rheumatological syndrome

pain and stiffness: neck, shoulder, pelvic girdle

worse in morning

lasts ≥1hr

maybe accompanied by systemic features:

• fever

• fatigue

• anoreixa

onset = 2wk - 2mo

• incidence increase with age

• average age of onset = 70yo

  • rarely \<50yo

• european descent

• F>M 2:1

• 50/100000 people over 50yo

• closely associated with GCA

  • but 2-3 times more common

• genetic and external factors

• ruling out other illnesses more important than immediately treating

  • cancers

  • insidious onset RA

Diagnosis

ruling in (compared to ruling out)

Inclusion

• Age >50yo

• symptom duration >2wk

• bilateral shoulder or pelvic girdle aching - or both

• Morning stiffness duration >45min

• Evidence of acute phase response

exclusion

• infection

• malignancy

• GCA

presentation

Pain

• shoulder pain 70-95%

• hip and neck = 50-70%

• upper arm pain common

• usually biltarel and symmetrical

  • may be worse on one side early in the course

• worsen with movement

• radiate -> elbows/knees

• tenderness

  • synovial/bursal inflammation

• weakness not a feature but may be difficult to distinguish this compared to pain

Stiffness

• morning stiffness that persists for at least 45min

• may be difficulty with ADL

systemic features

• 1/3

• low grade fever

• malaise

• anorexia

• weight loss

Peripheral symptoms

• pain/stiffness joints hands and feet = 50%

• consider other conditions

concurrent Giant cell arteritis

• unilateral temporal headaches

• scalp tenderness

• jaw claudication

• visual symptoms

DDx

• Giant cell arteritis

• malignancy

• RA and other arthritidies

• Endocrine/iatrogenic causes of prox. myopathy

  • hypothyroidism

  • Cushing’s disease

  • statin- induced myopathy/myalgia

• OA

• SLE/polymyositis

• Gibromyalgia and localised causes of pain

• Occult infection

  • Subacute bacterial endocarditis

Atypical features

• age \<60yo

• chroinc onset

• lack of shoulder involvement

• muscle weakness

• peripheral joint disease

• predominance of pain with little or no stiffness

• very high or normal CRP

• prominent systemic features

• lack of response to trial dose of prednisone

Investigations

• CRP

  • noraml acute phase response doens’t rule out PMR

  • CRP alone likely to be sufficient in most people

• FBC

  • most have mild-moderate anaemia

  • elevated WBC and platelet

• LFTs

  • 1/3 have mildly abnormal LFTs

    • ALP

• Cr and electrolytes

• consider:

  • TSH

  • RF/anti-CCP

  • Serum electrophoresis

  • CK

  • ANA

Treatment

• corticosteroids = first line

• plus Vit D

• consider bisphosphonates

• PPI

• Prednisone 15mg od for 3 weeks

• in morning with food

• Prednisone 12.5mg od for 3 weeks

• Prednisone 10mg OD for 4-6wks

• 1mg every 4-8wks

• measure CRP @ 4 weeks (should normalise)

• if symptoms patient returns to previous steroid dose

• low dose ‘tail’ need to be very gradual in some people to prevent symptom recurrence

• may need low does 2-3yrs

• after 2 relapses consider DMARD

  • methotrexate

• in general taper dose 10% every 2-4 weeks