How to manage a hospital in-patient with rhabdomyolysis (muscle breakdown) and Polymyalgia Rheumatica (PMR)?

Management of Hospital Inpatient with Rhabdomyolysis and PMR

For a hospital inpatient with rhabdomyolysis and Polymyalgia Rheumatica (PMR), aggressive intravenous fluid resuscitation should be initiated immediately while simultaneously addressing the PMR with glucocorticoid therapy at the minimum effective dose (12.5-25 mg prednisone equivalent daily). 1, 2

Initial Management of Rhabdomyolysis

Immediate Interventions:

• Aggressive intravenous fluid resuscitation
  • Target urine output of 300 mL/hour 3
  • This approach has been shown to decrease the incidence of acute renal failure and need for dialysis 2
  • Normal saline is the fluid of choice 2, 4

Laboratory Monitoring:

• Monitor creatine kinase (CK) levels (diagnostic when >5 times upper limit of normal) 3
• Check electrolytes frequently (especially potassium, calcium, phosphate)
• Monitor renal function (BUN, creatinine)
• Urine myoglobin testing to confirm diagnosis 3

Avoid:

• Bicarbonate administration (conditionally recommended against) 2
• Mannitol administration (conditionally recommended against) 2
• Loop diuretics (lack strong evidence for improved outcomes) 3

Concurrent Management of PMR

Glucocorticoid Therapy:

• Initiate prednisone at 12.5-25 mg daily 1
  • Lower end of range if patient has comorbidities (diabetes, osteoporosis, glaucoma)
  • Higher end of range if high risk of relapse with low risk of adverse events
  • Strongly avoid doses >30 mg/day 1

Baseline Assessment:

• Check inflammatory markers (ESR, CRP)
• Obtain rheumatoid factor and/or anti-CCP antibodies
• Consider checking creatine kinase (already part of rhabdomyolysis workup)
• Assess for comorbidities that may affect glucocorticoid therapy 1
• Consider vitamin D level and bone profile 1

Special Considerations for Combined Management

Potential Complications:

• Electrolyte imbalances - Monitor closely as both conditions can affect electrolyte status
• Renal function - Rhabdomyolysis can cause acute kidney injury; glucocorticoids may worsen hypertension and fluid retention
• Muscle weakness - Both conditions affect muscle function; distinguish between PMR symptoms and rhabdomyolysis

Treatment Modifications:

• If rhabdomyolysis is severe with significant renal impairment, consider:
  • Specialist nephrology consultation for possible renal replacement therapy 3
  • Rheumatology consultation for PMR management in setting of renal impairment 1

Monitoring and Follow-up

During Hospitalization:

• Daily monitoring of:
  • Urine output
  • CK levels (until trending down)
  • Renal function
  • Electrolytes
  • Clinical symptoms of both conditions

Discharge Planning:

• PMR follow-up visits every 4-8 weeks in the first year 1
• Individualized tapering schedule for glucocorticoids based on disease activity 1
• Patient education on:
  • Signs of PMR relapse
  • Symptoms of rhabdomyolysis recurrence
  • Glucocorticoid side effects to monitor
  • Importance of adequate hydration

Pitfalls and Caveats

• Avoid NSAIDs for PMR in this setting as they may worsen renal function in a patient with rhabdomyolysis 1
• Don't delay glucocorticoid therapy for PMR despite the presence of rhabdomyolysis, as untreated PMR can lead to significant morbidity
• Consider underlying causes of rhabdomyolysis that may be related to PMR or its treatment
• Watch for compartment syndrome as a complication of severe rhabdomyolysis requiring surgical intervention 3
• Monitor for adrenal insufficiency if patient has been on prior glucocorticoid therapy 5

By following this approach, you can effectively manage both conditions while minimizing complications and optimizing outcomes for the patient.