Review Question - QID 103081

This elderly woman with proximal muscle pain and stiffness and an elevated erythrocyte sedimentation rate likely has polymaylgia rheumatica. The most appropriate next step in management would be treatment with a corticosteroid.

Polymyalgica rheumatica classically affects patients over the age of 50, with women more frequently affected. The disease is characterized by pain and stiffness of the proximal muscles, such as the shoulders and pelvic girdle muscles. Patients often report difficulty standing from a seated position or performing overhead activity such as combing their hair. While weakness and muscular atrophy may occur in advanced cases, most patients do not have weakness. Laboratory evaluation characteristically reveals elevations in inflammatory markers such as erythrocyte sedimentation rate or C reactive protein. Management typically consists of a low dose corticosteroid. Notably, patients are at a particularly high risk for the development of giant cell arteritis, a large vessel vasculitis affecting the branches of the external carotid artery that can progress to visual loss and blindness.

Caylor, et. al reviews the current management of polymyalgia rheumatica. The main regimen typically employs the use of a slow taper (mean length is 1.8 years) of corticosteroids. Often times, there is a marked response shortly after initiating therapy. Those who continue to have disease flares and cannot tolerate corticosteroid taper may be candidates for disease-modifying anti-rheumatic drugs such as methotrexate and etanercept.

Salvarani, et. al describe that PMR and giant-cell arteritis frequently occur together. It is believed that they are different manifestations of the same disease process, as they both occur in patients above age 50, have high levels of acute-phase reactants before treatment, and show rapid response to steroids. 16-21% of those with PMR have giant-cell arteritis while 40-60% of patients with giant-cell arteritis have concomitant PMR. Furthermore, studies have shown high levels of macrophages and CD4+ T lymphocytes in joints of PMR patients.

Incorrect Answers:
Answer 2: Bisphosphonate medications are typically utilized for management of osteoporosis. Osteoporosis is generally asymptomatic in the absence of associated fractures, and would not explain this patient's proximal muscle pain and stiffness.

Answer 3: Hyaluronic acid is a medication sometimes used in the management of osteoarthritis. This patient's proximal muscle pain and stiffness are more suggestive of polymyalgia rheumatica.

Answer 4: Methotrexate is a medication typically used in the management of rheumatoid arthritis. Rheumatoid arthritis typically causes pain and stiffness in the joints of the hands and knees. It would not explain this patient's proximal muscle pain and stiffness.

Answer 5: Nonsteroidal antiinflammatory agents such as ibuprofen are occasionally used for patients with chronic musculoskeletal pain. However, this patient's history and presentation are more suggestive of polymyalgia rheumatica, which is more effectively managed with corticosteroids.

Bullet Summary:
Polymyalgia rheumatica is managed with corticosteroids.