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Although the glucocorticoids are the best treatment for polymyalgia rheumatic (PMR); they have been associated with cardiovascular risk factors such diabetes, hypertension and dyslipidemia. These adverse events increase the concern about cardiovascular disease. However a recent population based incidence cohort study (follow-up period: 7.6 years) found that elderly patients (mean age: 73 years) with PMR treated with glucocorticoids did not have a significantly risk of myocardial infarction, heart failure, peripheral vascular disease or cerebrovascular disease compared with those who did not receive glucocorticoids. On the contrary there was a trend for protective effect. This study showed that use of glucocorticoids is safe in these patients.

Maradit Kremers H, Reinalda MS, Crowson CS, Davis JM 3rd, Hunder GG, Gabriel SE. Glucocorticoids and cardiovascular and cerebrovascular events in polymyalgia rheumatica. Arthritis Rheum. 2007;57:191-2.

Competing interests: None declared

Competing interests: None declared

Cesar Augusto Guevara-Cuellar, Assistant Professor

University of Valle 25360

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Dear Sir,

Matteson and Michet1 give a comprehensive review of polymyalgia rheumatica (PMR). However, the overlap with giant cell arteritis (GCA) is the area that still causes much scalp scratching amongst rheumatologists and general practitioners.

Although, as the authors point out, GCA may present with the classic symptoms of headache and scalp tenderness, recent work using PET suggest that up to 30% of PMR patients have completely asymptomatic large vessel arteritis2. We now know that a significant number (up to a quarter) of GCA patients will go on to develop large vessel aneurysms, and long term follow up of GCA patients for this complication is now recommended in the US3. It may therefore be sensible to keep a closer long term eye on our PMR patients, and to aim for complete suppression of the CRP, even in asymptomatic patients.

1 Michet CJ, Matteson EL Polymyalgia rheumatica. BMJ 2008;336:765-9.

2 Blockmans D, De Ceuninck L, Vanderschueren S, Knockaert D, Mortelmans L, Bobbaers H. Repetitive 18-fluorodeoxyglucose positron emission tomography in isolated polymyalgia rheumatica: a prospective study in 35 patients. Rheumatology 2007;46:672-677

3 Nuenninghoff DM, Hunder GG, Christianson TJ, McClelland RL, Matteson EL.Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years..Arthritis Rheum. 2003 Dec;48(12):3522-31.

Competing interests: None declared

Competing interests: None declared

Mark E Lloyd, Consultant Rheumatologist

Frimley Park Hospital, Frimley, Surrey, GU16 7UJ

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Sir I read the article by Michet et al with interest(1). However, no mention was made of abnormal liver enzymes in polymyalgia rheumatica (PMR). Abnormalities of liver enzymes are common in several rheumatic conditions, including PMR. In one study, serum gamma glutamyl transferase level was elevated in 47% and serum alkaline phosphatase in 24% of patients with rheumatoid arthritis. A similar pattern was found in patients with ankylosing spondylitis, psoriatic arthritis, and reactive arthritis, and in 5 patients with polymyalgia rheumatica (2).

In another study of 74 patients with PMR, alkaline phosphatase was raised in about one-third of cases and became normal on treatment with steroids (3).

ALP is an acute-phase reactant and the frequently occurring increase of serum gamma glutamyl transferase and/or serum alkaline phosphatase in rheumatic diseases may be an non-specific reaction to inflammation. However, undelying subclinical abnormalities of hepatic canaliculi may also contribute to raised serum gamma glutamyl transferase/alkaline phosphatase activity in atleaset some of these patients.

In a study of 37 patients with PMR or temporal arteritis, 62% had elevated concentrations of serum alkaline phosphatase levels. BSP retention was studied in 13 patients and was abnormal in 6 (46%). Three of the 4 patients had an increase in alkaline phosphatase activity in their bile canaliculi. In one of these 3 patients, bile canaliculi had a calibre wider than normal and had granular walls (4).

In another study twenty-seven of the seventy four patients had elevated alkaline phosphatase levels. Isotope scans were abnormal in 7 of 29 patients and remained abnormal on follow-up (5).

Polymyalgia rheumatica/giant cell arteritis should be considered in the differential diagnosis in any patient above the age of 50 with unexplained abnormal liver enzymes.

(1)Michet CJ, Matteson EL. Polymyalgia rheumatica. BMJ 2008;336:765- 769.

(2)Akesson A, Berglund K, Karlsson M. Liver function in some common rheumatic disorders. Scandinavian J Rheumatol 1980; 9:81-8.

(3)Siebert S, Lawson TM, Wheeler MH, Martin JC, Williams BD. Polymyalgia rheumatica: pitfalls in diagnosis. J R Soc Med 2001; 94: 242–244.

(4)von Knorring J, Wassatjerna C. Liver involvement in polymyalgia rheumatica. Scandinavian J Rheumatol 1976; 5:197-204.

(5)Kyle V, Wraight EP, Hazleman BL. Liver scan abnormalities in polymyalgia rheumatica/giant cell arteritis. Clinical Rheumatology 1991; 10:294-7.

Competing interests: None declared

Competing interests: None declared

Habib U Rehman, Clinical assistant Professor

Regina Qu

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