New PMR research aims to improve treatment
Published on 29 October 2012
New research aims to raise awareness among GPs of the importance of early diagnosis in the commonly misdiagnosed condition, polymyalgia rheumatica. Jane Tadman reports.
Polymyalgia rheumatica, or PMR, is the commonest inflammatory rheumatic disorder affecting older people. Yet there is no standard diagnostic test, and GPs often struggle to diagnose it quickly or accurately.
PMR can strike quickly and come on within a week or two, causing pain in the muscles, usually in the shoulders and thighs, and can also lead to extreme stiffness first thing in the morning.
People with PMR can also feel completely exhausted and have a slight fever.
Unfortunately, these kinds of symptoms are similar to other types of inflammatory conditions, and GPs unfamiliar with the condition don’t always spot it early enough. Other more serious disorders that can mimic PMR are rheumatoid arthritis, lupus and even conditions such as lymphoma and Parkinson’s disease.
“The difficulty with PMR is that symptoms can be vague and non-specific, and the patient might also have osteoarthritis and other joint problems, so it’s easy to misdiagnose,” says PMR expert Professor Christian Mallen. “When someone presents with a typical textbook presentation it’s very easy to spot, but a ‘typical’ presentation is rarely typical.”
The problem of diagnosis has been identified among the medical profession and in 2011 the British Society for Rheumatology produced national guidelines aimed at helping all health professionals to recognise PMR, diagnose it and start the correct treatment early.
The guidelines make it clear that people with PMR whose condition doesn’t respond to steroids, or whose symptoms return as the standard therapy of steroid is tapered down, should be referred to see a rheumatologist. They also point to the use of additional therapies such as methotrexate and the need to keep a look-out for eye problems, as PMR is linked to a potentially serious eye condition called giant cell arteritis which, if left untreated, can lead to blindness.
However, rheumatology is littered with standards of care and guidelines that in practice are not routinely followed. These particular guidelines were largely developed by rheumatologists based in hospitals and now Professor Mallen is hoping that his new research will find out what’s happening at the grass roots of clinical practice – the GP surgery – where most people with PMR are actually treated.
Professor Mallen is a GP and now professor of general practice and Arthritis Research UK clinical scientist fellow at the primary care centre in Keele. As part of his fellowship he will be looking at whether more needs to be done to make sure the guidelines are adhered to, and if patients are getting the care and treatment they should get and at the right time.
To that end, over the next two years he’s planning to assemble the biggest-ever cohort of more than 800 patients with PMR in primary care, and follow them up regularly during the course of their disease, looking at the problems they encounter, how they respond to steroids and whether their symptoms fluctuate or gradually disappear over time. “It will be the first time we’ve followed the natural history of the course of the disease, so will provide a really good evidence base,” said Professor Mallen.
He is also working with Dr Toby Helliwell, a GP researcher who is sending a questionnaire to 5,000 GPs to find out more about current practice and how aware GPs are of the national PMR guidelines. These two linked pieces of research will be the first time that PMR has been closely studied in primary care and should shed more light on the reality of how it is treated in the real world.
Meanwhile, researchers at the Arthritis Research UK Primary Care Centre are doing their best to spread the word about the guidelines and the importance of early diagnosis. Professor Mallen is speaking about PMR in primary care at a one-day international symposium on PMR and GCA at Anglian Ruskin University in Chelmsford in November led by Professor Bhaskar Dasgupta, a leading rheumatologist specialising in PMR who was instrumental in the development of the guidelines and involving primary care clinicians in PMR research.
Arthritis Today will keep readers updated about the progress and outcome of Professor Mallen’s research.
A ‘typical’ case
In many ways Jeanne Wesson’s diagnosis of PMR was a textbook case. Two years ago, Jeanne, then 75, developed severe shoulder pain, which wasn’t helped by regular visits to an osteopath.
Over the Christmas period her body completely seized up. She was wracked with muscle pain that moved all over her body; couldn’t move, and fed herself on painkillers until her GP surgery opened after the Christmas break.
“I managed to get to the surgery with a piece of cardboard on which I’d written all my symptoms, and read them out to my GP. She said: ‘It sounds like polymyalgia to me,’ and that was that,” says Jeanne, who lives in Abingdon, near Oxford. Blood tests confirmed the speedy diagnosis, and she was put on steroids, plus drugs to reduce side-effects.
Like many people Jeanne did well on steroids and sees her GP regularly. Over the past couple of years the doses, and her condition, have fluctuated. She still has some pain and can’t walk long distances. She is also seeing the GP about the possibility of taking methotrexate as the condition is starting to affect her jaw and eyes.
However, Jeanne is very aware that she is extremely fortunate to have such a switched-on GP. ”I’ve been very lucky to have such a good practice,” she says. “I have friends with PMR who’ve had very different, bad experience with their GPs, and many of them didn’t get a diagnosis until they were sent to see a specialist.”
• Arthritis Research UK’s booklet on PMR is available on 0300 790 0400 or email@example.com