Diagnostic and management challenges of polymyalgia rheumatica (PMR) in general practice: a qualitative study

Problem

PMR is a debilitating inflammatory rheumatological disorder that affects older people. Most patients suffering with PMR are usually diagnosed and managed exclusively by their GP. However, diagnosis can be challenging and treatment with long-term glucocorticoids (usually prednisolone) is potentially associated with significant adverse effects especially among older adults where levels of multi-morbidity and polypharmacy are high. The aim of this study was to investigate in depth, the issues and challenges surrounding PMR diagnosis and management in general practice.

Approach

A national UK wide qualitative interview study of GPs was conducted. Participants were purposively identified from GPs who had previously indicated a willingness to participate in PMR research. Semi-structured interviews were conducted by telephone and all interviews were transcribed verbatim. The resulting manuscripts were analysed using thematic analysis

Findings

24 interviews were conducted. Themes relating to the challenges of diagnosis and management were identified.

For diagnosis, themes related to the process of developing the diagnosis and factors contributing to diagnostic uncertainty were identified. In developing the diagnosis, the non-specific and atypical presentations of PMR patients created difficulties. Patient presentation, rather than national guidelines, determined diagnostic work-up. . Features contributing to diagnostic uncertainty included the presence of normal inflammatory markers, poor response to initial treatment and the presence of multi-morbidity. Multi-morbidity had implications on both presenting features and the threshold of confidence in diagnosing and treating PMR Appropriate exclusion of differential diagnoses was challenging in primary care and a source of anxiety for those interviewed.

For management, two main themes were identified relating to the adverse effects of long term treatment with glucocorticoids (notably osteoporosis, hypertension, gastric symptoms and diabetes) and the impacts treatment has on existing co-morbidity. Consideration of prophylactic medications also caused significant dilemmas especially when multi-morbidity and polypharmacy co-were present. The second theme identified issues with disease monitoring. Sub-themes were identified relating to difficulties with timely and appropriate follow up, the resource implications of follow up and compliance to both prednisolone and prophylactic medications.

Consequences

PMR is a challenging disorder to accurately diagnose and manage effectively. As no gold standard test for PMR exists, successful diagnosis and treatment of PMR relies on an effective collaboration between patients and their GP, with appropriate access and follow up to ensure the right diagnosis and good on-going treatment concordance.

As GPs encounter a wide spectrum of illness in usual practice, and often have to manage multi-morbidity they are well placed to recognise, manage and monitor any developing potential adverse events from treatment with glucocorticoids.