Health: Polymyalgia Rheumatica and Giant Cell Arteritis

Lord Alderdice Excerpts

Wednesday 30th March 2011 Grand Committee

[Lord Alderdice]

My Lords, as the noble Lord, Lord Black of Brentwood, said, we are all grateful to the noble Lord, Lord Wills, for attaining this debate. The two noble Lords who have preceded me in the debate have pointed out a number of the problems of dealing with these disorders. The terms of the debate are polymyalgia rheumatica and giant cell arteritis. Although they are related disorders, there are important differences as well as overlapping and connections.

In the case of the condition that the noble Lord, Lord Wills, was particularly exercised about, he was talking really about temporal arteritis, as giant cell arteritis can happen in other places, the aorta, and so on. The question of early, rapid and irreversible blindness is really a function of temporal arteritis. Indeed, many people who have temporal arteritis also have polymyalgia rheumatica and probably about 15 per cent of those with polymyalgia rheumatica have temporal arteritis. They are overlapping and we do not really know why they come about but the management is very different.

As the noble Lord, Lord Black of Brentwood, pointed out, there are significant problems with the treatment with Prednisolone, although there is not much in the way of an alternative. Very early diagnosis is difficult because there are other disorders that are similar in their symptoms. Indeed, a noble colleague remarked earlier that, listening to the list of symptoms, she began to become concerned about herself. There are many different disorders that can cause some of the symptoms of polymyalgia rheumatica—some even in my professional background in mental disorders. Rushing into treatment may not actually be the best thing and there is not a pathognomonic diagnostic tool. For temporal arteritis it is quite different because, as the noble Lord, Lord Wills, said, it is crucial to get on with the treatment very quickly. If you do not, the blindness supervenes. You might get a good diagnosis but it is all too late. There is a clear diagnostic tool, temporal artery biopsy. It can be done by a physician, surgeon, or whomever, and very quickly the dose of Prednisolone can be instituted. If at all possible, it is better if the biopsy can be done first, and then, even before the biopsy has been looked at carefully, you can start with the treatment. If you start with the treatment immediately it tends the make the diagnostic problems of a biopsy a little more difficult, but the key thing is stopping the blindness.

One of the problems with the difference, overlapping and so on, is how one gets the message across to medical practitioners on how to deal with things, which was the burden of what the noble Lord, Lord Wills, was bringing to your Lordships’ and the Minister’s attention. It is very important to focus on the fact that we are talking about temporal arteritis leading to the blindness. Even the very term itself tends to focus the general practitioner’s mind on when he should become alerted to the range of symptoms, but focusing particularly on those things that might indicate temporal arteritis. In that case, he or she should quickly get a biopsy and start the treatment even before the results come back from the pathologist.

If you mix giant cell arteritis in general with polymyalgia rheumatica, you have a range of difficulties, disorders and treatment approaches that are complicated and cannot be diagnosed very clearly. There are lots of different tests that you might do, by which time the person is blind. That is exactly the kind of problem that the noble Lord has pointed out.

The noble Lord suggested raising the profile and having the Minister make a speech—I wholly agree with his sentiments about the standing of the noble Earl and the beneficent way in which he deals with these matters. He made a number of valuable suggestions about reference to NICE, getting matters across, a “Dear colleague” letter from the CMO, and so on. But, if the main concern is early, rapid treatment to prevent blindness, we need to focus specifically on temporal arteritis and move on quickly to treatment. If the burden of our concern is polymyalgia rheumatica, we ought to go a little more slowly and conservatively because there are other possible diagnoses. There are not obvious diagnostic tools and moving too quickly to treatment and not holding back can be, as the noble Lord, Lord Black of Brentwood, pointed out, more of a tragedy than the disorder itself.