Mary Ann E. Zagaria, PharmD, MS, CGPIndependent an elderly Care Consultant Pharmacist and President that MZ Associates, Inc.Norwich, new Yorkwww.mzassociatesinc.comPast Chair, board of Commissioners, Commission because that Certification in Geriatric PharmacyRecipient of the Excellence in Geriatric Pharmacy exercise Award from the Commission for Certification in Geriatric Pharmacy.

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US Pharm. 2016(41)22-19.

The variety of adults enduring from musculoskeletal ache (TABLE 1) has grown greatly with the rise in the geriatric population; over there are now 35 million human being aged >65.1,2 Arthritis, a particular kind of musculoskeletal disorder, is just one of the most typical conditions in the united States, and is the leading reason of disability and a significant factor in limiting quality of life.3,4 approximately one in five adults in the U.S. Has been diagnosed v some kind of arthritis.3 While the word arthritis is a mix of 2 forms at some point from Greek—arthr-, an interpretation “joints,” and also -itis, definition “inflammation,”—the hatchet refers no to one disease, but rather to a selection of illness that can cause joint pains or stiffness, damages to the structure of a joint, or ns of joint duty (TABLE 2).3 Arthritis may influence any share in the body, leading to pain and immobility to americans by the millions, follow to the nationwide Institutes the Health.5,6


There are plenty of factors that contribute to the breakthrough of arthritis, consisting of heredity, obesity, trauma, aging, lose of estrogen, occupational factors (i.e., heavy physical labor, such as that carry out by dockworkers, miners, and also furniture movers), medical conditions (e.g., specific metabolic disorders), and sports injuries.5 of note, while arthritis is regularly thought of together one disease, it actually occurs in more than 100 various forms, part that construct gradually an additional to wear of the joints, such together osteoarthritis (OA), and others the manifest acutely and wax and also wane.3 the is essential for healthcare experts to understand that OA and other “aches and pains” (TABLE 2) might overlap through inflammatory autoimmune diseases and disorders in an elderly person.


Inflammatory autoimmune conditions such as rheumatoid arthritis (RA) are reasonably common conditions, especially amongst adults aged >50.7 over 5% of females over 75 year of age have RA.4 Risk components for occurring an autoimmune condition include age and gender, among others.7 A recent study estimating the life time risk the RA (3.6% because that women and 1.7% because that men) and also other autoimmune illness indicates the the 2nd most typical autoimmune disorder is polymyalgia rheumatica (PMR), through a life time risk of 2.4% because that women and also 1.7% because that men.7,8 human being of north European and Scandinavian descent room at higher risk for emerging PMR; older adult are affected almost exclusively, v an average age at beginning of 70 years and also a range from 50 to 90 years.3,4

Signs and Symptoms

PMR beginning is dramatic and presents with bilateral proximal aching that the shoulder and hip girdle muscles and also the earlier and neck muscles; morning stiffness is typical (lasting >1 hour), and also discomfort might be such the patients are prevented from climbing out that bed in the morning and performing simple tasks.4,9 Bursitis is primarily responsible for shoulder symptoms; ache may reason subjective weakness, back muscle strength is typically unimpaired.4,9 Synovitis of the knees, wrists, and little joints that the hands—mild, transient, and without erosive changes—is often connected with PMR.4

Of note, both PMR and giant cabinet arteritis (GCA; additionally known together temporal arteritis) space related conditions of the elderly (TABLE 3). Patients should be warned around symptoms the GCA—headache (severe and also localized come the temple), muscle pain throughout chewing, and, in particular, intuitive disturbances—and should report them immediately to their healthcare provider since this condition may build at the onset of PMR or lot later, and even after ~ the patient’s disorder appears to be resolved.9


Diagnosis, Treatment, and also Prognosis

PMR is suspected in geriatric adult with typical symptoms; the differential diagnosis contains RA, polymyositis, hypothyroidism, many myeloma, and also fibromyalgia.9 The erythrocyte sedimentation rate (ESR) and also C-reactive protein (CRP) level are generally elevated in PMR, if rheumatoid factor is usually absent (TABLE 4).3,9 The ESR reading might be less advantageous in older adults, however; the precipitate rate rises with age, and also a regular level is more daunting to determine.3 Additionally, also during active inflammation, the CRP may not it is in elevated; the ESR and also CRP levels room often useful in monitoring the level of inflammation at any given point in time, and also in conjunction with symptoms, can be used as a tracking tool for treatment effectiveness.3,9


While aspirin and also non-steroidal anti-inflammatory drugs (NSAIDs) are noted to be reliable for soft symptoms, NSAIDs are hardly ever sufficient. The usual treatment is daily, low-dose corticosteroid therapy. While immediate and complete relief of symptoms is usually completed and resolution occurs in 1 come 2 years, both expert care and self-care are considered essential facets of management.3 Prednisone is initiated in ~ 15 come 20 mg orally when a day and also results in dramatic improvement within hours or days; this an answer may be used to support the diagnosis.9

As a allude of reference, the normal labeled dosage selection for dental prednisone in adults is 5 mg/day come 60 mg/day administered in one come four divided doses, depending upon the disease being treated, with individualization that dose and also titration come response.10 ~ symptoms are controlled, the dose is slowly diminished every 5 to 7 days.10 maintain doses in i m sorry prednisone is provided for chronic conditions are typically 10 come 20 mg orally as soon as a day, or 20 mg to 40 mg orally every various other day.10

If GCA is suspected to it is in present, 1) the dose of corticosteroids need to be higher: prednisone (unlabeled use) is offered initially, 40 to 60 mg orally daily, frequently requiring 1 to 2 years of treatment; however, a taper may start after 2 come 3 months; 2) alternative dosing the 30 come 40 mg orally every day has actually demonstrated comparable efficacy; and 3) a temporal artery biopsy have to be performed.9,11,12

There space no available specific guidelines for dosage adjustments the prednisone in renal impairment; it shows up that no dosage adjustments room required.10 Prednisolone is useful and also preferred come prednisone in patients with significant liver disease, since it does not call for hepatic activation.10,11 No dosage mediate of prednisolone is required in hepatic dysfunction.10 doses are equivalent (i.e., 1 mg prednisone is indistinguishable to 1 mg that prednisolone).10

Monitoring parameters incorporate measurement that blood pressure, weight, blood glucose (2-hour postprandial), and electrolytes; intraocular pressure (with usage of the medicine for >6 weeks); and also chest x-ray (if an extensive treatment).11,13 In patients through a background of peptic ulcer disease, top gastrointestinal (GI) x-ray must be considered.13 Additionally, there are special geriatric considerations about the usage of systemic prednisone in irradiate of the danger of adverse effects: usage cautiously in the elderly, in the smallest dose because that the shortest duration of time. If irreversible use is necessary, monitor bone-mineral density, academy fracture-prevention strategies, and consider the appropriateness of presenting a bisphosphonate to prevent osteoporosis.9,11 In elderly patients, pharmacists need to monitor for complications of corticosteroid use (e.g., diabetes, hypertension).9

Regarding the best dosage borders of prednisone, that is important to reiterate that the dosage must be individualized and also is extremely variable relying on the nature and also severity that the an illness and on patient response.10 Although there is no pure maximum dosage, the Boston Collaborative medicine Study found that psychiatric events occurred in fewer than 1% the patients when prednisone was prescribed in doses of 30 mg/day, whereas their incidence rose to 18% in patients receiving 80 mg/day.10,14

Some patients who room unable to have actually their prednisone sheep tapered and also who have frequent recurrences may advantage from the addition of methotrexate (10-15 mg orally once a week, if renal duty is normal) or one more immunosuppressant such as azathioprine.9 The addition of a 2nd agent in PMR or GCA is controversial, due to the fact that minimal benefit has been shown in controlled, randomized trials.9 No advantage has been presented in trials utilizing anti-tumor necrosis factor TNF agents (rituximab, infliximab, and adalimumab).9


It is important for pharmacists to understand that the musculoskeletal ache of osteoarthritis and the “aches and also pains” of other conditions may overlap v inflammatory autoimmune diseases and disorders in an elderly person. PMR, with its dramatic onset—and the related GCA—is an instance of such an inflammatory condition; it have to not it is in overlooked in the elderly, so that particular treatment may be initiated to provide relief indigenous pain.

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1. Laird R, Udeshi AR. Chronic musculoskeletal pain: early stage pharmacological and non-pharmacological therapies. Today’s Geriatric Medicine. 2016; Mar/Apr:10-14.2. Podichetty VK, Mazanec DJ, Biscup RS. Chronic non-malignant musculoskeletal pain in larger adults: clinical issues and opioid intervention. Postgrad Med J. 2003;79(937):627-623.3. Mei Clinic top top Arthritis. Rochester, Minnesota: mei Clinic; 2013:13-80.4. Scott DL. Arthritis in the elderly. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:566-576.5. Vad V. Arthritis Rx. New York, brand-new York: Gotham Books; 2006:19-56.6. Osteoarthritis. Nationwide Institutes that Health. U.S. Department of Health and also Human Services. Updated march 29, 2013. Https:// Accessed might 16, 2016.7. Polymyalgia rheumatica (PMR). WebMD. January 11, 2011. Accessed April 1, 2016.8. Crowson C, Matteson EL, Myasoedova E, et al. The lifetime risk that adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases. Arthritis Rheum. 2011;63(3): 633-639. Accessed April 1, 2016.9. Polymyalgia rheumatica. Last complete review/revision February 2016. Accessed might 13, 2016.10. Prednisolone. Revised in march 24, 2016. Http:// Accessed may 8, 2016.11. Semla TP, Beizer JL, Higbee MD. Geriatric Dosage Handbook. 20th ed. Hudson, OH: Lexicomp; 2015:1199-1201, 1202-1205.12. Hiratzka LF, Bakris GL, Beckman JA, et al. ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines because that the diagnosis and management that patients with thoracic aortic disease: executive, management summary. J to be Coll Cardiol. 2010;55(14):1509-1544.13. Epocrates Plus variation 15.12.1. Updated might 9, 2016. Accessed might 10, 2016.14. The Boston collaborative Drug surveillance Program. Acute adverse reactions come prednisone in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.15. Seetharaman M, Foster CS, Albertini JG, et al. Huge cell arteritis (temporal arteritis) workup. Update November 4, 2015. Http:// Accessed might 23, 2016.