Not simply aches and pains
Reproduced from Issue 108 of Arthritis Today
Understanding polymyalgia rheumatica and giant cell arteritis
Dr Brian Hazelman (pictured right) and Dr Simon Burnet, from the Rheumatology Research Unit at Addenbrooke's Hospital, Cambridge, dispel some myths surrounding this common and treatable condition.
What is polymyalgia rheumatica?
'Polymyalgia' means many aching, stiff muscles and 'rheumatica' means pertaining to the muscles, ligaments and joints. So polymyalgia rheumatica, (or PMR for short) is a painful condition that affects the muscles about the shoulder and neck region and also around the hip and thigh region. The symptoms of pain and stiffness can often be very severe and sometimes disabling. It is often worse in the morning but tends to ease throughout the course of the day. Patients may notice great difficulty dressing, walking, getting out of bed and even short periods of rest leads to worsening of the stiffness. Unlike the normal aches and pains of everyday life, PMR symptoms respond poorly to painkillers or anti-inflammatory drugs.
Sufferers may notice slight weight loss, a mild fever, fatigue and frequently experience low mood or even depression.
What is giant cell arteritis?
Giant cell arteritis, also called GCA or temporal arteritis, is a condition in which certain arteries (blood vessels) in the body become inflamed; particularly those around the temples. This causes headaches, pain in the jaw, when chewing, or tenderness of the scalp over the temples.
The inflammation of the involved artery leads to narrowing and sometimes to complete blockage of the blood vessel. This results in the surrounding tissue being deprived of an adequate blood supply. When GCA involves the arteries that supply blood to the eyes blurring of vision or even blindness in one or both eyes may occur. It is therefore important to inform your doctor if you have visual symptoms.
GCA often occurs with PMR. About 10 to 15 percent of people with PMR may also have GCA. About 50 percent of people with GCA also have PMR. However GCA can occur without PMR.
Who gets PMR?
The average age of people with this condition is 70 years and it is extremely uncommon before the age of 50 years. Women get PMR about two to three times more commonly than men and European people appear to be affected more commonly. It is a little more likely to occur if you have a family member with PMR.
What causes PMR?
The causes of PMR and GCA are not known. Because these are disorders that occur primarily in older people, it has been suggested that these conditions may be related somehow to the process of ageing.
Diagnosis
PMR is a syndrome, and unfortunately there are no specific tests and sometimes diagnosis can be delayed. Other conditions that cause symptoms similar to PMR such as rheumatoid arthritis need to be excluded before the diagnosis of PMR can be confidently made. Your doctor will usually request blood tests to establish the diagnosis and to make sure that there is no other cause for your symptoms. The most common test is called the ESR (Erythrocyte Sedimentation Rate). It is a measure of the inflammation in your body and may be raised in many conditions. The ESR is also used along with your symptoms to measure your response to treatment.
A biopsy of an affected blood vessel – usually the temporal artery is necessary to confirm GCA.
Can PMR and GCA be treated?
PMR treatment consists of reducing pain and inflammation, and easing stiffness and fatigue. The goal of treating GCA is to prevent damage to the tissues. The most commonly used medication is prednisolone. Usually patients with PMR respond very quickly and dramatically to low doses; patients with GCA usually require larger doses. Treatment often is required for two years or longer, in approximately 50% prednisolone may be discontinued. When symptoms are mild non-steroidal anti-inflammatory drugs may help pain and stiffness.
Your doctor will gradually reduce the tablet strength according to symptoms and the ESR. Even though you may feel well, be sure to see your doctor regularly for monitoring for relapse or side effects.
Are there any side effects from the medication?
You may have read or heard about some of the side effects of corticosteroids. When the dose is high, you may notice some weight gain especially around the abdomen and face. This depends on the dose, how long treatment continues, and varies between people. You may also notice thinning of the skin and bruising. These effects are much less obvious at a lower dose. If you have temporal arteritis the dose of steroids is higher and side effects more common. Your doctor will measure your blood pressure and your urine for sugar diabetes.
Corticosteroid may also lead to thinning of the bones, and maybe fractures. It is common practice now to protect your bones from this side effect with treatment. Make sure this is discussed with you.
What can I do to help myself?
As with the management of any rheumatic complaint, a regular physical therapy programme should be maintained by all. Exercise, in the form of regular walking, cycling or swimming, represent the easiest and best examples of this. There are no specific dietary restrictions advised but a balanced diet should be maintained.
When should I see the doctor?
Once the diagnosis of PMR has been confirmed and treatment has been commenced with prednisolone, the pain and stiffness should improve dramatically. If it does not or there is a worsening of the symptoms, then consult your doctor. If you develop a new headache or any new problems with your vision, then you should consult your doctor immediately.
Should I see a rheumatologist?
Most people who have PMR will have this diagnosed and treated by their general practitioner. In the cases where there is some difficulty with the diagnosis or there are complicating factors, then a referral to a rheumatologist will occur. All people with a possible diagnosis of temporal arteritis should be referred to a rheumatologist.
PMR is common, treatable and need not interfere greatly with your lifestyle. If you have further questions do not hesitate to ask your family doctor, nurse or specialist.
PMR and GCA rarely recur if you have been doing well for some time. Many people eventually are able to stop taking their medication after one or two years, but avoiding relapse requires close communication between you and your doctor.
