Clinical audit suggestions: polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in the elderly and is one of the biggest indications for long-term steroid therapy. There are difficulties in diagnosis, with heterogeneity in presentation, response to steroids and disease course.

Standards

The British Society for Rheumatology (BSR) and the British Health Professionals in Rheumatology (BHPR) guidelines for the management of polymyalgia rheumatica

Clinical knowledge summary

National Institute for Health and Care Excellence (NICE) clinical knowledge summary for the management of polymyalgia rheumatica

Audit criteria

Diagnosis

All patients with PMR:

• have been diagnosed using core inclusion and exclusion criteria (see standards above for these criteria), followed by assessment of the response to a standardised dose of steroid
• have documented in their medical record the minimum data set (the core clinical inclusion and any exclusion criteria and laboratory investigations before commencement of steroid therapy) which forms the basis for the diagnosis.
• should be signposted to information about their condition and this should be documented in their notes.

Treatment

All patients with PMR:

• without signs or symptoms of temporal arteritis or giant cell arteritis are treated with low-dose steroid therapy according to BSR and BHPR guidelines with gradually tailored tapering according to symptoms and inflammatory markers
• being treated with steroid therapy should be issued with a steroid treatment card.

Monitoring

All patients being treated for PMR:

• have laboratory monitoring every 3 months (full blood count, ESR/CRP, urea and electrolytes, glucose)
• have assessment of fracture risk and be offered bone protection as appropriate when initiating steroids, to prevent the complications of osteoporosis
• are monitored for response to treatment, disease activity, complications of disease (including symptoms of giant cell arteritis e.g. headaches, jaw claudication and large-vessel disease), atypical features or those suggesting an alternative diagnosis, adverse effects and complications of therapy according to this follow-up schedule: Weeks 0, 1–3, 6, Months 3, 6, 9, 12 in first year (with extra visits for relapses or adverse events).

Resources

Read code: N20 Polymyalgia rheumatica