JSS Academy of Higher Education & Research, Mysuru

(Deemed to be University – Accredited ‘A+’ Grade by NAAC)

JSS College of Pharmacy, Ooty

(An ISO 9001:2015 Certified Institution)

CASE TITLE - POLYMYALGIA RHEUMATICA

1. INTRODUCTION

 Polymyalgia rheumatica (PMR) is a relatively common chronic inflammatory

condition of unknown aetiology that affects elderly individuals. It is characterized by
proximal myalgia of the hip and shoulder girdles with accompanying morning
stiffness that lasts for more than 1 hour.
 Achiness is always worse in the morning and improves as the day goes by. Yet
inactivity, such as a long car ride or sitting too long in one position, may cause
stiffness to return. Stiffness may be so severe that it can affect daily day acitivity,
 It is an inflammatory condition associated with an elevated ESR and c-reactive
protein.

2. EPIDEMIOLOGY

 Polymyalgia rheumatica (PMR) is almost exclusively a disease of adults over the age
of 50, with a prevalence that increases progressively with advancing age. The peak
incidence of PMR occurs between ages 70 and 80.
 PMR is relatively common. The lifetime risk of developing PMR has been estimated
at 2.43 percent for women and 1.66 percent for men
 Women are affected two to three times more often than men
 Whites are affected more than other ethnic groups. PMR is only occasionally reported
in blacks.

3. ETIOLOGY

 The exact cause of polymyalgia rheumatica is unknown. Two factors appear to be

involved in the development of this condition:
 Genetics. Certain genes and gene variations might increase your susceptibility.
 An environmental exposure. Environmental trigger, such as a virus, might play a
role. But no specific virus has been shown to cause polymyalgia rheumatica.

4. PATHOPHYSIOLOGY

 The cause of PMR is not known, but inflammation is thought to occur due to an
autoimmune reaction causing the immune system to attack the synovium. The reason
for this is unknown. Environmental and genetic factors are thought to play a role.
5. RISK FACTORS

 Age. Polymyalgia rheumatica affects older adults almost exclusively. It most often

occurs between ages 70 and 80.
 Sex. Women are about two to three times more likely to develop the disorder.
 Race. Polymyalgia rheumatica is most common among white people whose ancestors
were from Scandinavia or northern Europe.

6. CLINICAL PRESENTATION

 Aches or pain in your shoulders

 Aches or pain in your neck, upper arms, buttocks, hips or thighs
 Stiffness in affected areas, particularly in the morning or after being inactive for a
time
 Limited range of motion in affected areas
 Pain or stiffness in your wrists, elbows or knees

7. DIAGNOSIS

 A physical exam, including joint and neurological exams, and test results can help
determine the cause of your pain and stiffness.
 During the exam, he or she might gently move your head and limbs to assess your
range of motion.
 Tests your doctor might recommend include:
 Blood tests-Two indicators of inflammation — erythrocyte sedimentation rate and C-
reactive protein.
 Imaging tests. Increasingly, ultrasound is being used to distinguish polymyalgia
rheumatica from other conditions that cause similar symptoms. MRI can also identify
other causes of shoulder pain, such as joint changes.

8. COMPLICATIONS

 Disrupts your sleep

 Limits your ability to do your usual activities.
 These difficulties can affect your health, social interactions, physical activity, sleep
and general well-being.

9. MANAGEMENT (Non-Pharmacological & Pharmacological)

Non-Pharmacology:
 Eat a healthy diet. Eat a diet of fruits, vegetables, whole grains, and low-fat protein
and dairy products. Limit the salt (sodium) in diet to prevent fluid buildup and high
blood pressure.
 Exercise regularly. Exercise that appropriate for you to maintain a healthy weight and
to strengthen bones and muscles.( daily walk,cycling, or swimming, jogging, walking,
tennis, dancing )
 Avoid sitting for any length of time may cause stiffness, making activities such as
driving more difficult. Stop from time to time on a long journey to stretch your
shoulders, arms and legs.
 Get enough rest. Rest is necessary for your body to recover from exercise and
activities of daily living.
 Vitamin D is needed to help the body absorb calcium.The best source of vitamin D is
sunlight on bare skin.
 Use assistive devices. Consider using luggage and grocery carts, reaching aids,
shower grab bars, and other assistive devices to help make daily tasks easier.

Pharmacology :
 CASE DISCUSSION – POLYMYALGIA RHEUMATICA
1. SUBJECTIVE

 Patient Name: Mrs.AB

 Age: 62 Yrs
 Gender : Female
 Chief Complaints: C/O Joint and upper limb pain, movement restriction, general
weakness and sleep disturbance due to the severity of the pain.
 Past Medical History: NIL
 Past Medication History:
The patient was treated with diclofenac gel with insignificant effect
 Social History: NIL
 Family History: NIL
 Allergies : N/K/A

2. OBJECTIVE
 O/E- Tenderness and palpitation of shoulder joint and muscles.
 General examination
 Weight: -
 PR –80bpm
 RR – 20/min
 Temperature: 101.4 F
 BP: 140/90mmHg
 CVS- -
 P/A – -

 Altered Laboratory Parameters:

Lab Parameters Normal Value Observed value

ESR 0-30 mm in 1sthour 50mm/hr

C Reactive protein 10 mg/L 24 mg/L

3. ASSESSMENT
  Polymyalgia Rhematica

4. TREATMENT GIVEN

Drug Dose Frequency

Methylprednisolone 16mg OD
Diclofenac 50mg OD
Pantoprazole 40mg OD

5. PHARMACISTS INTERVENTION

 According to American College of Rheumatology, NSAID are not effective in

treating polymyalgia rheumatica.
 Therefore, diclofenac should be discontinued
 Long term use of corticosteroid leads to loss of bone mineral density and higher risk
of vertebral fracture. So, calcium & vitamin D supplement is the rational therapy for
minimizing bone loss (The American College of Rheumatology recommends 1,000 to
1,200 milligrams of calcium supplements and 600 to 800 international units of
vitamin D supplements for anyone taking corticosteroids for three months or more.)
 The was patient was present with fever which was left untreated. So, acetaminophen
should be recommended.

6. PHARMACEUTICAL CARE PLAN

Drug Dose Frequency

Methylprednisolone 16mg PO OD
Paracetamol 500mg QID
Pantoprazole 40mg OD
Calcium 1000mg OD
Vitamin D 600 IU OD

7. PATIENT COUNSELLING

 REGARDING DISEASE:
 The patient was counselled about the diseases condition and complication of the
diseases.
 The patient was counselled about the sign and symptoms (Aches or pain in your
shoulders, aches or pain in your neck, upper arms, buttocks, hips or thighs)
 There's no cure for polymyalgia rheumatica. But with the proper treatment, symptoms
can improve in as little as 24 to 48 hours.
 REGARDING DRUG:
 Do not stop using the medicine without consulting doctor.
 Medicines should be given at the correct time with the correct dose.
 The missed dose should be taken as soon as remembered. Skip the next dose if it is
near the next scheduled dose.
 Pantoprazole should be taken 30min prior to the meal.
 Methylprednisolone shouldn’t be stopped abruptly, the dose should be tapered.

 REGARDING LIFE-STYLE:
 Eat a healthy diet. Eat a diet of fruits, vegetables, whole grains, and low-fat protein
and dairy products. Limit the salt (sodium) in diet to prevent fluid buildup and high
blood pressure.
 Exercise regularly. Exercise that appropriate for you to maintain a healthy weight and
to strengthen bones and muscles( daily walk, cycling, or swimming, jogging, walking,
tennis, dancing )
 Avoid sitting for any length of time may cause stiffness, making activities such as
driving more difficult. Stop from time to time on a long journey to stretch your
shoulders, arms and legs.
 Get enough rest. Rest is necessary for your body to recover from exercise and
activities of daily living.
 Vitamin D is needed to help the body absorb calcium.The best source of vitamin D is
sunlight on bare skin.

8. MONITORING PARAMETERS

 Methylprednisolone – Blood pressure, blood glucose, electrolytes; weight;

intraocular pressure (use >6 weeks); bone mineral density

9. REFERENCES
1. Polymyalgia rheumatica - Symptoms and causes [Internet]. Mayo Clinic. 2021 [cited
25 July 2021]. Available from: https://www.mayoclinic.org/diseases-
conditions/polymyalgia-rheumatica/symptoms-causes/syc-20376539
2. UpToDate [Internet]. Uptodate.com. 2021 [cited 25 July 2021]. Available from:
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-
polymyalgia-rheumatica#H2
3. Guggino G, Ferrante A, Macaluso F, Triolo G, Ciccia F. Pathogenesis of polymyalgia
rheumatica. Reumatismo. 2018;70(1):10-17.
4.Polymyalgia Rheumatica Guidelines: Guidelines Summary [Internet].
Emedicine.medscape.com. 2021 [cited 25 July 2021]. Available from:
https://emedicine.medscape.com/article/330815-guidelines
5.[Internet]. Wileymicrositebuilder.com. 2021 [cited 25 July 2021]. Available from:
https://wileymicrositebuilder.com/practicaldiabetes/wp-
content/uploads/sites/23/2018/06/Polymyalgia-rheumatica-AC-made.pdf
6. Caylor T, Perkins A. Recognition and Management of Polymyalgia Rheumatica and
Giant Cell Arteritis [Internet]. Aafp.org. 2021 [cited 25 July 2021]. Available from:
https://www.aafp.org/afp/2013/1115/p676.html
7. [Internet]. Rheumatology.org. 2021 [cited 25 July 2021]. Available from:
https://www.rheumatology.org/Portals/0/Files/2015%20PMR%20guidelines.pdf
8. [Internet]. Rheumatology.org. 2021 [cited 25 July 2021]. Available from:
https://www.rheumatology.org/portals/0/files/guideline-for-the-prevention-and-treatment-
of-giop.pdf