Ask The Doctors: June 2018
Q: I’ve had polymyalgia rheumatica for 10 years. I take low doses of prednisone. When I stop it, the symptoms return. Is there anything new to treat this disease?
A: Many older adults suffer with polymyalgia rheumatica (PMR), and researchers are looking for new ways to treat it. PMR is an inflammatory condition that causes aching and stiffness, primarily in the shoulders, hips and neck. It affects adults over age 50, but it usually begins around age 70. The cause of PMR is not known. There likely is a genetic component because it tends to run in families.
Symptoms tend to be worse in the morning, lasting for an hour or more. Severe stiffness can make it difficult to get up from a chair or raise your arms above shoulder height. Diagnosing PMR can be difficult because it mimics other disorders, such as rheumatoid arthritis, psoriatic arthritis, osteoarthritis and others. A doctor will look for typical symptoms and obtain a blood test to check for the presence of certain markers of inflammation.
The standard treatment for PMR is just what you are taking, which is corticosteroids. They improve symptoms for most people, but often must be taken long term. Unfortunately, there are several possible side effects associated with corticosteroids. For example, they can weaken bones. For this reason, your doctor will try to wean you off the drug or find the lowest dose that keeps you comfortable.
Because of the potential risks with corticosteroids, researchers are looking for other possible treatments for PMR. Rheumatologists will often add the drug methotrexate if it’s not possible to discontinue steroids. Studies of this approach have had mixed results. A small study using the drug tocilizumab (ActemraŽ) showed some promise, but more research is needed.
Q: I had an attack of severe pain and swelling in my ankle and knee. Fluid was drawn and tested for gout. But no crystals were found. I was diagnosed with pseudogout. What is pseudogout?
A: The symptoms of pseudogout imitate the symptoms of gout, as the name suggests. When you were told no crystals were found, your healthcare provider probably meant the type of crystals seen with gout were not present. Both gout and pseudogout are characterized by the build-up of crystals in joints. It’s just different types of crystals.
Pseudogout occurs when crystals called calcium pyrophosphate dihydrate (CPPD) collect in joints and areas surrounding joints. Having deposits of these crystals in joints is actually common as we age, and it doesn’t always cause symptoms. Why some people suddenly develop pain and swelling is not known. The joint most commonly affected by an attack of pseudogout is the knee, but other joints, such as the ankle, wrist, shoulder and elbow, can also be affected.
Gout most often affects the big toe, but you can also have an attack in other joints (knee, ankle, wrist or hand). Gout attacks occur as a result of uric acid crystals, which can form in people with high levels of uric acid in their blood. If a physician is uncertain whether joint pain and swelling are caused by gout or pseudogout, fluid will be drawn from the joint to examine under a microscope. The presence of uric acid crystals makes the diagnosis gout and CPPD crystals mean it is pseudogout.
Gout can be treated with drugs that lower uric acid levels. There’s no similar treatment that will prevent the formation of CPPD crystals. Treatment is aimed at relieving symptoms with nonsteroidal anti-inflammatory drugs, the drug colchicine or a corticosteroid injection.