Polymyalgia rheumatica and giant cell arteritis

Low doses of corticosteroid readily reverse the pain and stiffness of polymyalgia rheumatica, but only high doses can prevent the vascular complications of giant cell arteritis. The dilemma of therapy arises from the fact that giant cell arteritis can present subtly, with the same symptoms as polymyalgia rheumatica. Prescribing a high dose for all patients with such symptoms would certainly prevent vascular complications, but it would also put patients with polymyalgia rheumatica at needless risk of steroid side effects. In this article, Drs Wilske and Healey explain how to differentiate between these two inflammatory conditions on clinical and laboratory grounds so that the correct dose of steroid can be more confidently prescribed.     

Polymyalgia rheumatica and its links with giant cell arteritis

Polymyalgia rheumatica (PMR) was defined in 1957 and is linked with giant cell arteritis (GCA) in approximately 25% of cases. The peak incidence is between 60 and 75 years old and is increasing with the ageing population. Polymyalgia rheumatica is a clinical diagnosis without a 'gold standard' serological or histological test and there are other conditions that may mimic PMR. Treatment with a dose of 10-20 mg daily of prednisolone is suggested or 40-60 mg daily if GCA is also suspected. There are no absolute guidelines to the dose or its duration. The rate of reduction should be adjusted depending on the individual's response. Where temporal arteritis is suspected, this manifestation of GCA is a treatable medical emergency to prevent possible blindness, and steroids should be commenced immediately. There remain many unknowns in the cause, diagnosis and treatment of PMR and its overlap with GCA, and it is an ongoing challenge requiring further research.     

Polymyalgia rheumatica and giant cell arteritis. The dilemma of therapy

Polymyalgia rheumatica, next to rheumatoid arthritis the most common inflammatory rheumatic disorder of the elderly, is a nonspecific clinical syndrome involving pain in the shoulder and pelvic girdles. Giant cell arteritis appears to localize in elastin-containing arteries and can cause similar myalgias. A relationship exists between the two diseases, as evidenced by their frequent coexistence in the same patient. The symptoms of polymyalgia rheumatica respond to low-dose corticosteroid therapy, while giant cell arteritis requires higher doses to prevent blindness due to involvement of the temporal artery. The key decision in therapy, therefore, concerns the dose and duration of use of steroid for polymyalgic symptoms. In this decision, prevention of the catastrophic complications of giant cell arteritis and avoidance of needless side effects of high-dose steroid therapy in the elderly are competing considerations.     

Polymyalgia rheumatica and temporal arteritis

Polymyalgia rheumatica and temporal arteritis are a clinical syndrome and clinicopathologic entity, respectively. Polymyalgia rheumatica occurs more commonly than temporal arteritis, with approximately half of all patients with temporal arteritis having the polymyalgia rheumatica syndrome. Both conditions are found in the population over 50 years of age and are associated with an elevated ESR. The etiology of both is unclear, although genetic, and potentially, environmental factors may play significant roles. Both conditions respond to corticosteroid therapy, but patients with temporal arteritis require significantly higher doses to control symptoms and to prevent blindness.     

Polymyalgia rheumatica and giant-cell arteritis

The subjects of the study were 112 patients with rheumatic polymyalgia (RPM) and giant-cell arteritis (GSA). The study shows that RPM and GSA are complicated by cerebral flow disturbances and myocardial infarction. Therapy with prednisolone and non-steroid antiinflammatory drugs reduces the risk of these complications and lethal outcome in patients with RPM and GSA.     

Polymyalgia rheumatica and giant-cell temporal arteritis

The article is dedicated to the contemporary concept of the prevalence, etiology, and pathogenesis of polymyalgia rheumatica and Horton's disease. The author analyzes the features of the pain syndrome, arthritis, fever, and other manifestations of the disease. Taking into consideration the fact that polymyalgia rheumatica and Horton's disease are usually revealed too late, the author pays special attention to their diagnostics and differential diagnostics. An increased ESR is a feature of this disease. Polymyalgia rheumatica is treated with prednisolone. The stages of glucocorticoid therapy, the rules of adjustment and lowering prednisolone doses, combined therapy with glucocorticoids and cytostatics, the effectiveness of therapy, and the prognoses are described in detail.     

Management of giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis and polymyalgia rheumatica are closely related disorders that affect persons more than 50 years of age and cause substantial morbidity. Patients with giant cell arteritis typically have a localized headache, nonspecific systemic symptoms, temporal artery tenderness and a high erythrocyte sedimentation rate (ESR). The diagnosis is confirmed by characteristic pathologic findings on temporal artery biopsy. Patients with polymyalgia rheumatica usually have similar nonspecific systemic symptoms, proximal muscle pain and stiffness, and an elevated ESR. The diagnosis is based on the clinical findings. Both disorders are treated with corticosteroids: high dosages for giant cell arteritis (prednisone in a dosage of 40 to 60 mg per day) and lower dosages for polymyalgia rheumatica (prednisone in a dosage of 10 to 20 mg per day). Symptom relief in response to treatment is rapid and reinforces the diagnosis. After normalization of the ESR, the corticosteroid is tapered, with the patient monitored closely for symptom recurrence. Most patients require corticosteroid therapy for two to three years and experience one or more treatment complications.     

Polymyalgia rheumatica and temporal arteritis: a case presentation

Polymyalgia rheumatica (PMA) and temporal arteritis (TA) are common clinical syndromes that affect the elderly population. Both syndromes may include similar constitutional complaints, an increase in acute phase reactants, a rapid response to corticosteroids, and the presence of anteritis giant cells upon temporal artery biopsy. Differential diagnosis is one of exclusion. A case presentation is included to assist practitioners in recognizing presenting symptoms, identifying diagnostic testing, and proceeding with appropriate therapy and follow-up.     

Factor VIII-von Willebrand factor in giant cell arteritis and polymyalgia rheumatica

Levels of three factor VIII-von Willebrand factor components (von Willebrand antigen, ristocetin cofactor, and factor VIII coagulant) were higher in specimens of plasma from 27 patients with giant cell arteritis and 18 patients with polymyalgia rheumatica than in specimens from 21 normal control subjects. Values in patients with active giant cell arteritis were higher than those in patients with either inactive giant cell arteritis or active polymyalgia rheumatica. Levels of factor VIII-von Willebrand factor components tended to decline gradually after disease activity had been suppressed by corticosteroid therapy and therefore may be indicators of vascular damage. These levels, however, did not revert to normal rapidly in response to corticosteroid therapy as did the patients' symptoms and the usual laboratory measurements indicative of inflammation; thus, measurements of these components are unlikely to be useful in day-to-day management of these diseases. Electrophoretic analysis suggested that the elevated values are due to increased amounts of normal factor VIII-von Willebrand factor rather than to the presence of an abnormal molecule.     

Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a disease of unknown etiology characterized by severe myalgia and stiffness at shoulder girdle and pelvic girdle muscles and by normal serum creatine kinase levels. Marked elevation of erythrocyte sedimentation rate, acute onset within two weeks, and appearance in the aged are also additional characteristics of PMR. Ten to 50% of PMR patients have a concomitant temporal arteritis (TA)(giant cell arteritis). For the differential diagnoses of PMR, rheumatoid arthritis, polymyositis, fibromyalgia, malignancies, infections and depression should be considered. PMR without TA is treatable successfully with small amount of steroids (15-20 mg/day of prednisolone). For the PMR patients with TA should be treated with large amount of steroids (40-60 mg/day of prednisolone) or steroid pulse therapy.     

Polymyalgia rheumatica and temporal arteritis. Related conditions with differing therapies.

Polymyalgia rheumatica and temporal arteritis are entities seen chiefly in older adults. Polymyalgia rheumatica is characterized by muscle and joint aches and an elevated erythrocyte sedimentation rate, and it responds rapidly to low-dose corticosteroid therapy. Temporal arteritis is a vasculitic process, the diagnosis of which must be established by invasive procedures. Higher doses of steroids are necessary to treat it, and the potential for steroid-induced side effects is high.