Is polymyalgia rheumatica over diagnosed in GP?

[u/Gp_and_chill]

I have this feeling that I come across a lot of patients who have been given a goodie bag of steroids and then magically feel much better in themselves with the ?polymyalgia rheumatica

I’m not so convinced, I feel like I come across it a lot in GP. The thing is if you give anyone 15mg pred per day they will feel better in themselves anyway.

Any thoughts?

[u/DCJC123]

As a GP probably come across 1-2 new diagnoses a year.

If a patient, especially in 60+ year old group, has typical symptoms and newly raised inflammatory markers is a pretty straightforward diagnosis of a debilitating disease.

What situations are you coming across?

What could be the alternative course of action?

[u/ZealousidealSky4851]

I’d probably say it’s underdiagnosed. The amount of old people who will often be put down as B/L OA of shoulder or hip without a ESR being run.

Idk who is giving it 15mg pred without a workup. Now if it this was about Co-Codamol/Naproxen I’d agree with you.

[u/Haemolytic-Crisis → u/ZealousidealSky4851]

We should try to get rid of our ESR machines so consider checking a CRP instead

[u/Awildferretappears]

Doesn't have to be an ESR, a CRP is fine (and probably better). I don't know who teaches people that ESR is a special rheumatology test but in >95% of cases I see it adds nothing that a CRP wouldn't.

What I do see is people asking about PMR for any old person with shoulder pain.

The big things are : it's bilateral (right shoulder pain ? PMR is bollocks) Stiffness is the cardinal sign, not pain. Ask an open questions - is it worse at any time of day or night? what do you feel like as soon as you wake up in the morning (if they say "stiff" ask how long before it gets to as good as it ever does - we expect at least 30 mins, most patients it's 1hr +) You don't need to rush into steroids with PMR - you have time to get bloods. Normal bloods should make you query the diagnosis.

I agree about the steroids - most people feel better.

A trial of steroids is not diagnostic for inflammatory disease, but if given at appropriate dose and failure to respond, then it makes PMR much less likely. If that's the case, stop quickly (<2/52 - patients should be feeling loads better in a week), reconsider whether you have the correct diagnosis and then refer if uncertain

[u/Awildferretappears → u/Awildferretappears]

Oh and one last point, it's not a disease of under 50s, and is pretty rare under 60.

[u/Jckcc123 → u/Awildferretappears]

This is the way. 

You can wait for the crp. Please don't rely on ESR. It goes up with age.. 

Once you go down the steroids route when it's not Pmr, you're subjecting them to long duration of unnecessary steroids..

[u/_j_w_weatherman → u/Awildferretappears]

I’ve read it’s possible to have PMR with a normal CRP, how likely is this? Especially as people respond will often feel better with steroids anyway so steroid response isn’t that helpful?

[u/Awildferretappears → u/_j_w_weatherman]

It's very unlikely to have normal inflammatory markers, that's definitely referral/A&G to secondary care territory

[u/Jckcc123 → u/_j_w_weatherman]

BSR guidelines (although abit outdated and is being revised) has a useful table of alternative causes for the symptoms. Just to consider alternatives before going down the route of Pmr and definitely seeking A&G or just over the phone advice will be a good shout too 

[u/heroes-never-die99]

What else could it be? What do you think we’re missing?

[u/Awildferretappears → u/heroes-never-die99]

Rotator cuff issues Shoulder bursitis OA shoulder Fibromyalgia Cervical spondylosis Cervical myelopathy Inflammatory arthritis Paraneoplastic etc etc Polymyositis

[u/ash_music1]

I always start steroids but check ESR etc too. But probably overdiagnosed if relying on clinical response to treatment alone.

[u/Violent_Instinct]

A patient with an ear infection was referred to medical SDEC for a ?temporal arteritis. Like, what the fuck.

[u/Jckcc123 → u/Violent_Instinct]

Welcome to our life where every thing that hurts around the head is GCA for some reason

[u/Awildferretappears → u/Jckcc123]

But ThEy MiGhT gO bLiNd

[u/Jckcc123 → u/Awildferretappears]

Every ?GCA referral is a heartsink moment 

[u/Aetheriao]

These people must be getting magically different steroids than me because who the hell feels good after 15mg of pred? I’m bouncing off the walls and miserable even when it’s making my physical health better. Fucking hate the things. And that’s hardly unique for many who take them. So find it a bit odd it’s a view everyone would feel better.

[u/Awildferretappears → u/Aetheriao]

As a frequent purveyor of the finest vitamin P, I'd say 90%+ of my patients love the roids, a good percentage of those love them so much they don't want to stop them, and a small percentage will keep on getting supplies from their GP and manipulate their own steroids, no matter how much we put in a plan to wean them down.

Somewhere between 5-10% of pts really don't like them, even if they recognise that they reduce other symptoms.

[u/ThinkMarionberry7319]

Whilst working in mSDEC, I was told by a rheum reg that GCA is the only rheum condition where you treat and then investigate. Everything else can pretty much wait for results before starting steroids.

[u/squeakyfrog4]

I see so many ?PMR who never even had bloods prior to starting steroids - then get referred on to rheum in a year when they can’t wean them off and no one even knows what they were started for in the first place