I NFLAMMATORY R HEUMATIC
D ISEASES IN THE E LDERLY
Bhaskar Dasgupta MD, FRCP
Consultant Rheumatologist, Honorary Professor,
Essex University
Southend University Hospital
Email: bhaskar.dasgupta@southend.nhs.uk

One of commonest inflammatory disease of the elderly
Commonest indication for long term steroid therapy in the community
Wide variation of practice
Diagnostic uncertainty
Many causes of prox pain & stiffness
Systemic symptoms
APR – many causes
Association with GCA
Steroid response

H EALTHCARE BURDEN OF PMR
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GPRD database Incidence in England 8.4 per 10,000 personyears
Prevalence > 50 years estimated at 739 per 100,000, with higher prevalence in females
Associated with a significant incremental cost of $2,233 at the
10 th percentile of costs and $27,712 at the 90 th percentile
Mainly for co-morbid CVS conditions, hospital stays , Imaging
More likely to have: a history of myocardial infarction (odds ratio [OR]: 1.78, 95%
CI: 1.13, 2.82) peripheral vascular diseases (OR: 2.21, 95% CI: 1.37, 3.60) cerebrovascular diseases (OR: 1.60, 95% CI: 1.08, 2.39)
Dasgupta et al Handbook of Disease Burden Springer Science 2010 Chapter 233

L ARGE V ESSEL A RTERITIS
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Giant cell arteritis - Common in the West, uncommon in India
Takayasu’s aorto-arteritis - Has predilection for certain geographical areas I.e. Japan, South-East
Asia, India, South America, milder form in North
America

I MPORTANCE OF GCA
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Commonest of the vasculitides
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Neuro-ophthalmic complications
One of the commonest causes of acute blindness
Need for careful disease assessment to maintain an acceptable balance between risks and benefits of steroid therapy

C LASSIFICATION CRITERIA GCA
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1. Age at disease onset  50 years
2. New headache -- New onset of or new type of localised pain in the head
3. Temporal artery abnormality
4.Elevated erythrocyte sedimentation rate  50 mm/hour
5. Abnormal artery biopsy----Biopsy specimen with the artery showing vasculitis characterised by prominence of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells.
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For purposes of classification, a patient with vasculitis shall be said to have giant cell (temporal) arteritis if at least 3 of these 5 criteria are present.

E PIDEMIOLOGY OF PMR AND GCA
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Age and sex are risk factors
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Increasing incidence through successive decades
Female:Male = 2.5-3:1
Common in Caucasians of Northern European origin
Rare in Asians and Afro-caribbeans

E PIDEMIOLOGY CONTD
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Variable incidence 9.3 -27/100,000 >50yrs
Suggestion of cyclical pattern
Association with environmental agents: adenovirus, RSV, Mycoplasma,parvovirus B19, chlamydia pneumoniae, HPIV
Chlamydia found by PCR in TA biopsies
‘Actinic’ hypothesis

C URRENT STATE OF PRACTICE
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BSR/BHPR have published guidelines on the diagnosis and management of PMR and GCA
Guidelines have been adopted by the Royal
College of Physicians
However there is still little hard data on diagnosis, course, outcomes and complications of
PMR and GCA
Newly formed organisation PMRGCAUK has as its objective supporting research and increasing awareness of these conditions
Many unanswered questions remain

Q UESTIONS
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What is the incidence of PMR and GCA in South
East Essex?
What is the prevalence of PMR and GCA in SE
Essex?
How are PMR and GCA managed in SE Essex?
What are the outcomes and complications of PMR and GCA in SE Essex?
What is the provision of services for these conditions?

P LAN
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To develop a Registry for the diagnoses of PMR and GCA across SE Essex
Circulate definitions of PMR and GCA across all
GP practices
Implement educational training programmes for recognition of these conditions
Develop a standardised data-gathering template for these conditions
Notification of all new PMR and GCA to central registry

PMR AND GCA REGISTRY
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How are PMR and GCA diagnosed?
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How are PMR and GCA investigated?
How are PMR and GCA managed?
Incidence of complications
Time trends
Seasonal trends
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Geographical and socio-economic variation

C OLLABORATION
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Between
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Southend University Hospital
NHS SE Essex
?Essex University
Work with RDS for a grant application
PMRGCAUK
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Develop web-based data gathering?