Mary Ann E. Zagaria, PharmD, MS, CGPIndependent an elderly Care Consultant Pharmacist and also President that MZ Associates, Inc.Norwich, brand-new Yorkwww.mzassociatesinc.comPast Chair, board of Commissioners, Commission for Certification in Geriatric PharmacyRecipient the 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 number of adults enduring from musculoskeletal ache (TABLE 1) has actually grown greatly with the boost 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 common conditions in the united States, and also is the leading reason of disability and also a major factor in limiting high quality of life.3,4 approximately one in five adults in the U.S. Has actually been diagnosed with some form of arthritis.3 While the word arthritis is a mix of two forms ultimately from Greek—arthr-, meaning “joints,” and -itis, meaning “inflammation,”—the ax refers no to one disease, however rather come a variety of illness that can cause joint pains or stiffness, damage to the structure of a joint, or lose of joint duty (TABLE 2).3 Arthritis may impact any share in the body, resulting in pain and also immobility to americans by the millions, according to the national Institutes that Health.5,6


There are numerous factors that contribute to the development of arthritis, including heredity, obesity, trauma, aging, loss of estrogen, occupational components (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 the note, when arthritis is frequently thought of as one disease, it actually occurs in much more than 100 various forms, part that develop gradually secondary to wear of the joints, such together osteoarthritis (OA), and others the manifest acutely and also wax and wane.3 that is crucial for healthcare specialists to recognize that OA and also other “aches and also pains” (TABLE 2) may overlap through inflammatory autoimmune diseases and disorders in an elderly person.


Inflammatory autoimmune diseases such as rheumatoid arthritis (RA) are fairly common conditions, especially among adults aged >50.7 end 5% of women over 75 years of age have RA.4 Risk determinants for occurring an autoimmune disease include age and gender, among others.7 A recent study estimating the life time risk the RA (3.6% for women and also 1.7% because that men) and also other autoimmune conditions indicates that the second most usual autoimmune disorder is polymyalgia rheumatica (PMR), v a life time risk the 2.4% for women and 1.7% for men.7,8 world of northern European and also Scandinavian descent are at greater risk for emerging PMR; older adult are impacted almost exclusively, v an average period at start of 70 years and a selection from 50 to 90 years.3,4

Signs and also Symptoms

PMR beginning is dramatic and also presents v bilateral proximal aching of the shoulder and also hip girdle muscles and also the earlier and neck muscles; morning stiffness is usual (lasting >1 hour), and also discomfort might be such that patients room prevented from increasing out the bed in the morning and performing basic tasks.4,9 Bursitis is primarily responsible because that shoulder symptoms; pain may cause subjective weakness, return muscle toughness is typically unimpaired.4,9 Synovitis that the knees, wrists, and tiny joints that the hands—mild, transient, and also without erosive changes—is often associated with PMR.4

Of note, both PMR and giant cell arteritis (GCA; additionally known together temporal arteritis) are related conditions of the yonsei (TABLE 3). Patients must be warned about symptoms of GCA—headache (severe and also localized to the temple), muscle pain throughout chewing, and, in particular, intuitive disturbances—and must report them automatically to their medical care provider due to the fact that this condition may construct at the start of PMR or much later, and even after the patient’s disorder appears to it is in resolved.9


Diagnosis, Treatment, and Prognosis

PMR is doubt in geriatric adults with usual symptoms; the differential diagnosis includes RA, polymyositis, hypothyroidism, many myeloma, and also fibromyalgia.9 The erythrocyte sedimentation price (ESR) and also C-reactive protein (CRP) levels are frequently elevated in PMR, while rheumatoid element is usually missing (TABLE 4).3,9 The ESR reading might be less helpful in larger adults, however; the sedimentation rate increases with age, and a typical level is more challenging to determine.3 Additionally, even during energetic inflammation, the CRP may not be elevated; the ESR and CRP levels room often valuable in monitoring the level of inflammation at any kind of given suggest in time, and in conjunction v symptoms, can be offered as a tracking tool for treatment effectiveness.3,9


While aspirin and also non-steroidal anti-inflammatory drugs (NSAIDs) are detailed to be effective for soft symptoms, NSAIDs are seldom sufficient. The usual treatment is daily, low-dose corticosteroid therapy. If immediate and also complete relief of symptom is usually accomplished and resolution wake up in 1 come 2 years, both professional care and self-care are taken into consideration essential facets of management.3 Prednisone is initiated at 15 come 20 mg orally when a day and results in dramatic improvement within hours or days; this response may be offered to support the diagnosis.9

As a allude of reference, the normal labeled dosage selection for oral prednisone in adult is 5 mg/day come 60 mg/day administered in one to four divided doses, depending on the disease being treated, through individualization the dose and titration to response.10 after ~ symptoms room controlled, the sheep is slowly diminished every 5 come 7 days.10 maintain doses in i m sorry prednisone is used for chronic conditions are normally 10 to 20 mg orally when a day, or 20 mg come 40 mg orally every other day.10

If GCA is suspected to it is in present, 1) the sheep of corticosteroids need to be higher: prednisone (unlabeled use) is given initially, 40 come 60 mg orally daily, typically requiring 1 to 2 year of treatment; however, a taper may start after 2 to 3 months; 2) different dosing that 30 come 40 mg orally per day has actually demonstrated comparable efficacy; and 3) a temporal artery biopsy should be performed.9,11,12

There are no available specific guidelines for dosage adjustments of prednisone in renal impairment; it appears that no dosage adjustments space required.10 Prednisolone is useful and preferred to prednisone in patient with far-reaching liver disease, because it does not require hepatic activation.10,11 No dosage adjustment of prednisolone is essential in hepatic dysfunction.10 doses are tantamount (i.e., 1 mg prednisone is equivalent to 1 mg of prednisolone).10

Monitoring parameters include measurement the blood pressure, weight, blood glucose (2-hour postprandial), and also electrolytes; intraocular pressure (with use of the drug for >6 weeks); and chest x-ray (if lengthy treatment).11,13 In patients through a history of peptic ulcer disease, top gastrointestinal (GI) x-ray have to be considered.13 Additionally, there space special geriatric considerations regarding the usage of systemic prednisone in light of the threat of adverse effects: use cautiously in the elderly, in the the smallest dose because that the shortest duration of time. If long-term use is necessary, screen bone-mineral density, institute fracture-prevention strategies, and also consider the appropriateness of presenting a bisphosphonate to stop osteoporosis.9,11 In yonsei patients, pharmacists should monitor for complications that corticosteroid use (e.g., diabetes, hypertension).9

Regarding the maximum dosage borders of prednisone, it is crucial to reiterate the the dosage have to be individualized and is very variable depending upon the nature and also severity the the disease and on patience response.10 Although over there is no absolute maximum dosage, the Boston Collaborative medicine Study found that psychiatric events emerged in fewer than 1% the patients as soon as prednisone to be prescribed in doses of 30 mg/day, whereas their incidence climbed to 18% in patients receiving 80 mg/day.10,14

Some patient who are unable to have actually their prednisone sheep tapered and also who have regular recurrences may benefit from the enhancement of methotrexate (10-15 mg orally as soon as a week, if renal role is normal) or another immunosuppressant such as azathioprine.9 The addition of a second agent in PMR or GCA is controversial, due to the fact that minimal benefit has been presented in controlled, randomized trials.9 No advantage has been displayed in trials utilizing anti-tumor necrosis element TNF agents (rituximab, infliximab, and also adalimumab).9


It is necessary for pharmacologists to understand that the musculoskeletal ache of osteoarthritis and the “aches and pains” the other conditions may overlap v inflammatory autoimmune diseases and disorders in an elderly person. PMR, v its dramatic onset—and the related GCA—is an instance of such an inflammatory condition; it should not it is in overlooked in the elderly, so that details treatment might be initiated to carry out relief indigenous pain.

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1. Laird R, Udeshi AR. Chronic musculoskeletal pain: early pharmacological and also non-pharmacological therapies. Today’s Geriatric Medicine. 2016; Mar/Apr:10-14.2. Podichetty VK, Mazanec DJ, Biscup RS. Chronic non-malignant musculoskeletal pains in older adults: clinical issues and opioid intervention. Postgrad Med J. 2003;79(937):627-623.3. Mei Clinic ~ above Arthritis. Rochester, Minnesota: mayo Clinic; 2013:13-80.4. Scott DL. Arthritis in the elderly. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook the Geriatric Medicine and also Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:566-576.5. Vad V. Arthritis Rx. New York, new York: Gotham Books; 2006:19-56.6. Osteoarthritis. Nationwide Institutes of Health. U.S. Room of Health and 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 life time risk that adult-onset rheumatoid arthritis and also other inflammation 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 for the diagnosis and management that patients through thoracic aortic disease: executive, management summary. J am 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 cooperation Drug surveillance Program. Acute disadvantage reactions come prednisone in relationship to dosage. Clin Pharmacol Ther. 1972;13:694-698.15. Seetharaman M, Foster CS, Albertini JG, et al. Huge cell arteritis (temporal arteritis) workup. Updated November 4, 2015. Http:// Accessed might 23, 2016.