Polymyalgia rheumatica

definition

The polymyalgia rheumatica is an inflammatory and, as the name implies, rheumatic disease. It manifests itself through inflammation of blood vessels, the arteries that pump the blood from the heart into the body. It occurs with a frequency of 50 people per 100, 000 inhabitants, so not so rare.

It mainly comes to muscular pain in the shoulder and pelvic girdle, as in most cases, the main artery, and arteries of the upper limb are affected by the inflammation. Affected are usually over 60 years old. It is accordingly a disease of advanced age. Women are two to three times more likely to be affected than men.

In about 50% of cases, polymyalgia rheumatica is associated with a so-called giant cell arteritis. The two diseases overlap and are not strictly separable. In giant cell arteritis, so-called giant cells are detectable in the tissue examination. It usually occurs in the supply area of ​​the carotid artery. In about 20% of patients with polymyalgia rheumatica, temporal artery disease (inflammation of the temporal artery) occurs as a form of giant cell arteritis.

Guideline

The guideline for the diagnosis and treatment of polymyalgia rheumatica, developed since 2015, is based on scientific studies. The goal is to achieve the best possible treatment outcome for the patient by applying guidelines, and to standardize therapies worldwide. Unfortunately, the guideline on polymyalgia rheumatica is still being prepared and is expected to be published in 2017. According to statements made so far, however, the therapy procedure usually used in Germany will be confirmed by the guideline.

causes

One real cause why some people get polymyalgia rheumatica while others do not, has not yet been found. It is believed that facilities for the disease are genetically inherited. Most likely, the disease is triggered by an autoimmune process. In an autoimmune disease, cells of the immune system falsely attack the body's own cells.

laboratory values

Polymyalgia is a disease that belongs to the vasculitis (diseases associated with vascular inflammation). The disease can lead to an increase in inflammatory values. These include, for example, the CRP value, the leukocyte count in the blood and the erythrocyte sedimentation rate. Polymyalgia rheumatica, however, is not a disease diagnosed on the basis of laboratory tests. Only the erythrocyte sedimentation rate plays a role in the diagnosis. However, a normal erythrocyte sedimentation rate does not exclude the presence of the disease.

symptoms

As a leading symptom there is relatively strong pain in the area of ​​the muscles of the upper half of the body, that is, especially games such as the shoulder, the neck and the hip are affected. The symptoms start relatively quickly with the onset of the disease. Typical of a rheumatic disease is that the pain usually occurs at night. The pain is present at rest, as well as during exercise.

In the morning there is often a stiffness of the affected parts. The morning run in the bathroom is difficult for many patients. By increasing movement during the day the symptoms will be better. In some patients, general symptoms of illness such as fever, loss of appetite, fatigue, lack of exercise, weight loss and night sweats occur. In some cases, the disease can also be accompanied by severe depression.

If there is headache in the area of ​​the temple and visual disturbances at the same time, this indicates a parallel temporal arteritis. The artery can often be felt thickened and seen.

diagnosis

The polymyalgia rheumatica is mainly diagnosed by a blood sample. In the blood one can then find out that certain inflammatory parameters (CRP and BSG value) are increased. Partly, the number of white blood cells (leukocytes) is increased. Although the muscle is painfully affected in the case of polymyalgia rheumatica, it is typical for the disease that the laboratory value of creatine kinase (CK), the increase of which is indicative of damage to the musculature, is not increased.

In many rheumatic diseases, one can still detect a so-called rheumatoid factor, but this is not the case with the polymyalgia rheumatica. In addition to the laboratory findings, the symptoms of the patient are groundbreaking. There is a definite diagnosis for polymyalgia rheumatica if at least four points are achieved from the listed list with the following criteria:

  • Morning stiffness longer than 45 minutes (2 points)
  • Rheumatoid factor and / or anti-CCP antibodies are negative (2 points)
  • Pain in the pelvic girdle or limited flexibility in the hip joint (1 point)
  • otherwise no other joint painfully affected (1 point)
  • both shoulders show inflammatory changes detected by ultrasound (1 point)
  • as well as at least one shoulder and hip joint is affected inflammatory (1 point)

Furthermore, a therapy attempt can be started in case of a justified suspicion of illness. Therapy is usually with so-called glucocorticoids, including cortisone belongs. If the pain improves with the administration of cortisone, the diagnosis is also assured.

Course of a polymyalgia rheumatica

The course of polymyalgia rheumatica depends on how quickly a therapy with cortisone is initiated. Left untreated, the disease can cause discomfort for years. The complaints can occur in spurts. Thus, phases of the disease may alternate with little or no symptoms, as well as disease phases with severe symptoms. If it occurs together with a temporal arteritis, there is an untreated risk of blindness. After the start of the drug treatment, the symptoms usually appear in the background after a few days. Not to forget, however, are the side effects that can occur in the context of cortisone therapy. Although this therapy is very effective, cortisone therapy can cause many undesirable effects such as osteoporosis, stretch marks development, gray or green star development, diabetes mellitus, fat distribution disorders with a full moon face or bull neck, and immunodeficiency.

treatment

The therapy takes place as already mentioned with the administration of glucocorticoids (cortisone). Their effect is mainly due to an anti-inflammatory effect, which reduces the pain. Cortisone works very fast, so the pain usually improves within hours to a maximum of days. If the symptoms improve as the therapy progresses, the dose of cortisone preparation may be reduced step by step to reach a dose that is unlikely to produce side effects. The dose should never be lowered too fast, because the signs of inflammation and the pain then directly increase again.

However, if the therapy does not start directly or diminishes its effect, the dose must be increased again. Therapy with cortisone should be for a period of two years. The long-term therapy should reduce the risk of regressive illness. Previously, the disease was treated with significantly higher cortisone doses, so that the disease was successfully treated, but then the sufferer suffered from the consequences of cortisone therapy. The side effects often led to the development of osteoporosis. This usually does not occur today due to the reduced dose.

As a precaution, all patients are typically prescribed calcium and / or vitamin D supplements in parallel with cortisone therapy for prophylaxis. If therapy is not adequate, methotrexate may be used as a support so that the dose of cortisone does not have to be excessively increased. Methotrexate suppresses the immune system, which leads to an improvement in the symptoms due to the supposedly autoimmune component of the disease.

Dosage of cortisone

Depending on whether it is a pure polymyalgia rheumatica or a combination of polymyalgia and temporal arteritis (also called giant cell arteritis or Horton's disease), the dose of cortisone therapy is different. If temporal arteritis is present as well, a high dose of 100 mg cortisone per day is usually recommended. This is because temporal arteritis is at risk for blindness. Such high-dose cortisone shock therapy should avoid this.

In a pure polymyalgia rheumatica usually a starting dose of 20-30 mg cortisone per day is sufficient. It is taken in the morning, because here the cortisol level of the body is the highest and the intake is therefore most physiological. The cortisone therapy usually has to be continued over a longer period of time. The goal, however, is to slowly reduce the dose over time. In case of polymyalgia with arteritis, the dose is reduced to 20-30 mg per day after at least two months. If a pure polymyalgia rheumatica is present, the dose can usually also be lowered after about two months, for example to 10-15 mg per day. Subsequently, the further stepwise dose reduction takes place. After about 6-9 months, the dose can be reduced to below 7.5 mg per day. This is the threshold dose under which it should come to less serious side effects in a long-term cortisone therapy. A complete adjustment (ie a further dose reduction until complete discontinuation of therapy) is usually attempted at the earliest after two years.

Treatment - Without cortisone

Cortisone therapy is definitely the best therapy for polymyalgia rheumatica. Nevertheless, many patients can not make friends with a long cortisone therapy because of the side effects. Unfortunately, there is no reasonable or even remotely comparable alternative to therapy with cortisone, so that therapy with cortisone is actually essential.

One alternative, although not cortisone-free, is to treat with immunosuppressants such as methotrexate, so that lower cortisone therapy can be used right from the start. Especially in the initial phase you can not pass on a cortisone therapy unfortunately.

Homeopathic treatment of polymyalgia rheumatica

There are many homeopathic remedies that can be used to treat polymyalgia rheumatica. First and foremost here is Traumeel®, a substance that is supposed to have an anti-inflammatory effect. Aesculus-Heel drops, Hamamelis-Homaccord drops or Arteria-Heel drops can also be used. The effect of homeopathic substances, however, has not been scientifically proven. Especially if it is a polymyalgia with additional arteritis temporalis, it can come to untreated dangerous courses, since here the eyesight can be acutely endangered. In any case, a doctor of traditional medicine should be consulted in a timely manner. The only proven effective therapy for polymyalgia is cortisone therapy.

Nutrition in Polymyalgia rheumatica

Polymyalgia rheumatica is a vasculitis, an inflammatory disease of the vessels. The diet does not play an essential role in the disease. However, due to the treatment with cortisone preparations, which is often necessary over a longer period of time, it may be useful to take certain supplements. Cortisone has many potential side effects as part of long-term therapy. One of these is the weakening of the bone structure with the resulting development of osteoporosis. In order to counteract this as effectively as possible, it may be useful to take regular vitamin D and calcium supplements. These counteract the weakening of the bone structure, since they are actively involved in the bone structure.

Duration of polymyalgia rheumatica

As mentioned above, the duration of the disease episode depends on how fast a drug therapy with cortisone is started. Left untreated, it can last for years. After the start of cortisone therapy, the symptoms usually disappear within a few days.

forecast

The prognosis of polymyalgia rheumatica is relatively good. In most cases, low-dose cortisone therapy will be sufficient for at least one year to control the inflammation. Therapy will continue for another year to avoid relapse.

However, a recurrence may occur even after the disease has resolved, this can never be ruled out, because the underlying inflammation does not completely disappear through therapy, but is only suppressed. At the earliest after two years you should try to stop the medication and watch if the symptoms recur and the therapy must be continued accordingly.

Cure of a polymyalgia rheumatica

Polymyalgia can be treated very well with cortisone shock therapy. This means that the symptoms are prevented by a longer-term drug therapy. Many patients do not experience the symptoms afterwards. However, there are also recurrences, ie a recurrence of the disease after successful treatment.

Likelihood of relapse

After successful treatment of the disease, it may in some cases come to a relapse, ie a recurrence of the symptoms. One then speaks of a recurrence. How high the recurrence rate is exactly is not clear. In general, many patients respond to cortisone therapy very well and do not relapse.

Alcohol and polymyalgia rheumatica - is that OK?

In general, there is no scientific proof that alcohol enhances the symptoms of polymyalgia rheumatica. However, there are those who report that the pain increases after drinking alcohol. It should also be borne in mind that cortisone therapy is necessary to treat the condition. Caution should be exercised when combining cortisone and alcohol. This does not mean that a complete renunciation of alcohol is needed, but the consumption should be significantly reduced.


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