Polymyalgia Rheumatica and Giant Cell Arteritis

The basic pathology of this very important disease complex is giant cell arteritis (synonyms: temporal arteritis; cranial arteritis). The clinical syndromes are polymyalgia rheumatica and temporal arteritis.

Clinical features of polymyalgia rheumatica

• Pain and stiffness in proximal muscles of shoulder and pelvic girdle, cervical spine

• Symmetrical distribution

• Typical ages 60–70 yrs (rare <50)

• Both sexes: more common in women

• Early morning stiffness lasting >45 mins.

• May be systemic symptoms: weight loss, malaise, anorexia, fever

Clinical features of temporal arteritis (TA)

• New headache—unilateral, throbbing

• Visual symptoms, e.g. diplopia

• Temporal artery tenderness

• Loss of pulsation of temporal artery

• Jaw claudication

• Biopsy of artery (5 cm) is diagnostic

Investigation

• No specific test for polymyalgia rheumatica

• ESR—extremely high, typically >40, may be around 100; ↑ CRP

• Mild anaemia (normochromic, normocytic)

Treatment (refer any patient with GCA immediately)

Prednisolone:

• Starting dose: temporal arteritis usually 1 mg/kg, 60 mg average; polymyalgia rheumatica 15 mg

• After 2–4 wks, taper down gradually (max. 10% wkly) to min. effective dose (often <5 mg/d) according to the clinical response and the ESR. Aim for treatment for 2 yrs: relapses are common.

Azathioprine or methotrexate can be used as steroid-sparing agents.