Editor – Dasgupta, writing on behalf of the polymyalgia rheumatica (PMR) guideline development group, presents a welcome and thorough overview of this common condition (Clin Med June 2010 pp 270–4). I have concerns with the recommended three-monthly ‘lab monitoring’ of full blood count, erythrocyte sedimentation rate/C-reactive protein (ESR/CRP), urea and electrolytes and glucose. The management of straightforward PMR is to relieve symptoms (and not to treat inflammation) until the condition runs its natural course. Steroid withdrawal should be based on the clinical picture and not on the level of ESR and this is alluded to in the article ‘raised ESR/CRP without clinical symptoms is not an indication to continue corticosteroids’.
It is my belief, based on reviewing many patients with PMR and iatrogenic Cushing's/osteoporosis, that the main reason for the continuation of higher dose steroids is the regular checking of an ESR to follow disease activity. The secret to the successful management of straightforward PMR is, once the diagnosis has been made, never to check an ESR/CRP unless there is a clinical indication.
Polymyalgia rheumatica
Editor – We thank Dr Morris for highlighting an important issue – the objectives of steroid treatment for polymyalgia rheumatica (PMR). Steroids are prescribed for their important effect on pain, disability and stiffness and the quality of life in untreated PMR is lower than in most other comparable conditions. On the other hand steroids also have many side effects and over-treatment based on raised inflammatory markers alone may prolong duration of treatment and induce treatment co-morbidities such as fractures, diabetes, hypertension, weight gain and cataracts.
However, we now know that the PMR constitutes only one of many conditions that can present with bilateral shoulder pain and stiffness. Such conditions include late onset rheumatoid arthritis, other arthropathies, spondyloarthropathies and connective tissue diseases. Large vessel vasculitis may also present with polymyalgia, constitutional symptoms and raised inflammatory markers. Other serious pathology, such as systemic infection, disseminated cancer and so on, may also be mistaken as PMR and may have an initial response to high dose steroids.
We therefore stand by our recommendation of inflammatory marker testing in the context of a clinical review – especially in the first year of disease. Transient elevations of CRP/ESR may be due to common causes such as urinary or chest infections and urinalysis and chest radiographs may be considered. Persistent elevation in the presence of definite symptoms suggests partial or non-response to steroids, search for alternative pathology or adjuvant immunosuppresives and a specialist referral. Persistent symptoms in the absence of elevated markers suggests evaluation of co-existing non-inflammatory conditions such as osteoarthritis, rotator cuff and other local shoulder conditions, fibromyalgia, etc. These conditions should be dealt with by explanation, reassurance and local treatments such physiotherapy, injections and exercises; while the steroid dose is tapered.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- Royal College of Physicians
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- Royal College of Physicians
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