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PMR and underlying cancer

Posted , 7 users are following.

gee013
gee013

my 77 year old father has had PMR for nearly 5 years and still takes 20 mg of prednisolone. Currently he is on 35 mg after a nasty fall and injury. I have read somewhere that resistant PMR can be a sign of an underlying malignancy. Appart from feeling unwel, poor walking and painful spasms in his hands and low back there dont seem to be any other clues. Any advice?

2 likes, 14 replies

14 Replies

  • bronwyn97278
    bronwyn97278 gee013

    Posted

    Oh Gary;  that's a bit hard to make a call.....I would hate to jump into saying "yes he has cancer"....that's definately for trained medical professionals....am wondering though; when he had his fall, did he hurt his back/damage any discs?....if they were fractured (which can be very easily done in the elderly/and on Prednisone)....do you  know has he got any fractured Spinus Processess (the bits that stick out from the part of the backbone that protects the spinal cord)....this maybe causing extra pain, and if there is some compression of a nerve...this would cause difficulty/pain in the extremities.....this is a Very hard call to make, and really feel that he should be reviewed by his GP and have his x-rays reviewed  (I assume he had some done after his fall)???             Bron
  • EileenH
    EileenH gee013

    Posted

    Is the doctor sure it is PMR? To be left on 20mg and upwards pred is poor practice in PMR and his doctor should have been investigating other options. PMR and LORA can appear to be almost the same and LORA doesn't respond well to pred on its own. Any patient who requires 20mg pred for any time and is unable to reduce the dose either probably doesn't have PMR but another arthritis or is one of the maybe 1 in 4 patients for whom pred doesn't work. Malignancy should have been ruled out in the differential diagnosis of the PMR - there are only certain things that commonly cause PMR symptoms - and it is certainly not the first conclusion to jump to. However - I think I might like to have my father seen for a second opinion.

    Have you thought of trying Bowen therapy for the low back problems?

  • MrsO-UK_Surrey
    MrsO-UK_Surrey gee013

    Posted

    Gary, if your father has been on Prednisolone for 5 years and is not able to reduce from the 20mg dose to control his pain his PMR pain then he should have been investigated to check for a different diagnosis, for instance late onset rheumatoid arthritis, rather than malignancy.  He should, in any case, be having regular blood tests.  Also, I'm wondering how he has been trying to reduce the steroid dose?  Sometimes GPs advise patients to reduce by the same method as those patients who take short term steroid doses for other illnesses such as asthma, but that doesn't work for PMR.  It should be reduced in very tiny steps, remaining on each new dose for several weeks at a time.  But, having said this, the main aim is to reduce to the lowest dose that still controls the inflammation, thereby reducing the potential side effects at the high doses.  I'm not surprised that your father is having difficulty walking, as the long term high dose has probably weakened his muscles.

    After what you describe as a "nasty fall and injury", I would hope that he has been referred for an MRI to see the extent of that injury and if any treatment, such as physio, would help, rather than increasing the steroid dose to 35mg.  Doses as high as that and above are really reserved for those patients suffering from the linked condition, GCA - they are not necessary or recommended for those with PMR.

    Is your father under a rheumatologist?  if not, he should be.  If he is under a GP, then he needs to see a diferent one.  And, has he been referred to an orthopaedic consultant following his fall and injury?  If it is a rheumatoligst who is treating him, he needs to find another one.

  • gee013
    gee013

    Posted

    Thanks for the responses. He lives on one of the Channel Islands with a population of a large town. There is a rheumy who visits the Island every couple of months from the UK Mainland. He was pretty confident of the diagnosis at the beginning and since then has seen the Rheum Nurse Specialist a couple of times only. Im not very happy and asked his GP last week to expedite aan appointment with the consultant. They do not have a choice as there is only one that visits the Island. He has got down to 17 mg on a few occasions with slow reductions, but not below that. His back ached before the fall and seems no worse. I will ask my brother if he had xrays. Most of the damage was grazed bruised face and skinned right arm and leg. The skin sheared off from above knee to ankle and above elbow to wrist. They replaced it in A&E(ER) and dress it regularly by visiting nurses. 
    • Oregonjohn-UK
      Oregonjohn-UK gee013

      Posted

      If he lives in Guernsey there is Dr Raymond Armstrong

      Rheumatology (BUPA) who works at the Princess Elizabeth Hospital in St Peter Port?

    • Oregonjohn-UK
      Oregonjohn-UK

      Posted

      Shoud be visits but it's private!!   A Consulant visits for 4 days each month from the hospital my wife work at the Southampton General.
    • bronwyn97278
      bronwyn97278 gee013

      Posted

      I am really sorry fo your Dad....the skin shearing is bad enough....this is common with elderly people (in itself), but the Prednisone would be making his skin More fragile....I, too, feel that he needs "better help"...as in my first reply....he needs further investigation...can he be brought over to the Mainland...or is he not willing to leave his home?....Bron
    • MrsO-UK_Surrey
      MrsO-UK_Surrey gee013

      Posted

      Gary, ouch for your poor father.  Unfortunately, steroids cause thinning of the skin which can then tear very easily at the slightest knock as many of us have experienced.  There is an excellent cream/gel available either on prescription or over the counter which, used regularly, will moisturise his skin and help protect it from the easy tears.  t's called Doublebase - I discovered it purely by chance when some years ago a podiatrist recommended it for the dry, thin skin on the soles of my feet which was encouraging seed corn growth.  I decided to try it  on the steroid-thinned skin on my arms and legs initially, found it so helpful so used it on the rest of my body throughout my remaining years on steroids and ever since.

      I'm not surprised that you're not "very happy" with the circumstances. Neither would I be.  If the rheumy is visiting the Island every couple of months thenwhy is he not seeing your father during those visits, not just leaving him to the rheumy nurse who is obviously not au fait with the need to get that long term very high steroid dose down or investigate him for something other than PMR.  I do hope something can be resolved so that your father's health and quality of life improves. 

  • gee013
    gee013

    Posted

    Dear PMR friends, writing to give you an up date with the strange developments. My father has not seen the rheum for 2 years, appointments keep being cancelled. Now new Geriatrician has rapidly reduced his pred with no adverse consequences so far now down to 7 from 35. But his ESR is still 97 and CRP 28. So my question still remains. Could he have something else underlying?? Cannot get the specialist to talk directly to me and I live too far away to go with him next appointment.
    • EileenH
      EileenH gee013

      Posted

      It is fairly likey that there is something else going on - but I imagine the geriatrician is waiting to get his pred dose down to nearer zero before he can investigate to find out what. Pred can mask all sorts of things. It sounds as if your father is far better off with the geriatrician than he was with the rheumatologist.

      I have just found an article from the Royal college of physicians of Australia which says: "Acute back pain, in the setting of constitutional symptoms and a markedly elevated ESR, prompts investigation for infection, such as discitis or a paravertebral abscess, as well as malignancy, such as myeloma or metastatic disease. Myeloma is one of the archetypal diseases associated with an elevated ESR."

      That should have been looked for at the outset - maybe it wasn't and an assumption was made that since pred helped it was PMR. Of course, things can also change with time so maybe the current illness is not the same as it was at the beginning or what it was then was not severe enough to identify and then the pred covered up further symptoms. The fact that he couldn't reduce the pred dose should have triggered further investigation - that isn't typical of PMR and should have made them look further.

      I'm sending you the link to the paper in a pm as I can't put it here without it disappearing for moderation.

    • gee013
      gee013 EileenH

      Posted

      Thanks. Seen Armstrong again who now says it probably wasnt/isnt PMR! 

      My father asked.

      1. Is the anaemia due to the PMR?

      2. Why is it two years since he ws last seen, when he ws initially told he would be seen annually?

      Dr A refused to answer anything. He seems to be the only rheumatologist who visits Guernsey so there are no other options. Apparently hhe is not gifted with good commications skills or bedside manner. One outcome was he had a Ct scan abdo today and xrays of knees and ankles.......

    • EileenH
      EileenH gee013

      Posted

      That's a start I suppose. I think that rheumatologists have become the new surgeons! They always had the reputation of being arrogant and non-communicative but there are rheumies who can give them a run for their money these days!
    • bronwyn97278
      bronwyn97278 gee013

      Posted

      Hi Gary; I know that different countries have different rules; but, here, if your father was to give a "signed consent form"  (similar to A Power of Attorney in relation to his Health)   to the specialist, he should then give you (or the person nominated on form", the answers to ALL the questions that you are asking......whether it be test results/diagnosis/prognosis etc.......can you ask your father to do this....it may help your situation??................Bron
    • gee013
      gee013 bronwyn97278

      Posted

      A letter has already been put in the notes from my father to give permission to the professional for all discussion to include me.
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