Polymyalgia rheumatica

Date: 09 Feb 2020

By: admin_campbell

Comment: 0

Causes
Diagnosing polymyalgia rheumatica
Introduction
See what the doctor sees with Map of Medicine
Symptoms of polymyalgia rheumatica
Treating polymyalgia rheumatica

Polymyalgia rheumatica – NHS Choices

@import url(‘/css/reset.css’) screen;
@import url(‘/css/screen.css’) screen;
@import url(‘/css/healthaz.css’) screen;

<!–

//

Skip to main content
Skip to main navigation
Help with accessibility

var MSOWebPartPageFormName = ‘aspnetForm’;

//

Polymyalgia rheumatica

Introduction

A stiff or painful neck can be a sign of polymyalgia rheumatica

Giant cell arteritis

Around one in five people with polymyalgia rheumatica develop a more serious condition called giant cell arteritis (also known as temporal arteritis), which can cause inflammation in the arteries of the head or neck, resulting in symptoms such as:

persistent severe headaches with scalp tenderness (the scalp is sore to touch)
pain in the jaw muscles when chewing
impaired vision, such as double vision or loss of vision

You should contact your GP immediately if you notice these symptoms.

Unlike polymyalgia rheumatica, giant cell arteritis is regarded as a medical emergency and without prompt treatment it can cause permanent visual impairment.

The symptoms of giant cell arteritis can develop before, after or at the same time as the symptoms of polymyalgia rheumatica.

Read more about giant cell arteritis.

Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.

Polymyalgia rheumatica may also cause other symptoms, including:

a high temperature (fever)
extreme tiredness (fatigue)
loss of appetite
weight loss
depression

If you have pain and stiffness that lasts longer than a week, you should see your GP so the cause can be investigated.

It can be difficult to diagnose polymyalgia rheumatica because it has symptoms similar to many other conditions, such as rheumatoid arthritis. These conditions will need to be ruled out before polymyalgia rheumatica is diagnosed.

Read more about the symptoms of polymyalgia rheumatica and diagnosing polymyalgia rheumatica.

How is it treated?

The main treatment for the condition is a steroid medication (corticosteroids) called prednisolone, which is used to help relieve your symptoms.

You will initially be prescribed a high dose of prednisolone, which will be reduced gradually over time.

Most people with polymyalgia rheumatica will need to take a long-term course of corticosteroid treatment (lasting one to two years) to prevent their symptoms returning.

Read more about treating polymyalgia rheumatica.

Who is affected?

Polymyalgia rheumatica is relatively common in the UK. It is estimated that one in every 1,200 people develop the condition every year.

Polymyalgia rheumatica is an age-related condition. Most people diagnosed with the condition are over 70 years old and cases affecting people younger than 50 are almost unheard of.

The condition is two to three times more common in women than men. It is more widespread among white people, particularly those of northern European descent.

The cause of polymyalgia rheumatica is unclear. However, it is thought that a combination of genetic and environmental factors is responsible.

Page last reviewed: 28/01/2013

Next review due: 28/01/2015

Ratings

How helpful is this page?

Average rating

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

Based on
476 ratings

All ratings

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

199
ratings

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

157
ratings

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

31
ratings

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

13
ratings

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

76
ratings

Add your rating

Unhelpful
Not very helpful
Fairly helpful
Helpful
Very helpful

Comments

The 17 comments about ‘Polymyalgia Rheumatica And Giant Cell Arteritis’ posted are personal views. Any information they give has not been checked and may not be accurate.

User909837 said on 07 October 2014

I was diagnosed with PMR in 2013 at the age of 46. I know this is extremely young but after ruling out other illnesses, (I was initially treated for Fibromyalgia, with no success), my doctor prescribed Prednisolone. Within 24 hours I was fully mobile and pain free! I’d had to take time off work and returned in July for 2 days a week. I’m currently on 3 days now but still get ‘wiped out’ and have to rest up for 1-2 days. Unfortunately, I am in the process of reducing my Prednisolone and the pains, stiffness and mobility are increasing again. Is this what I have to look forward to for the rest of my life, being tired, in pain and immobile? What can I proactively do to get rid of this? RSVP

lylacavanaugh said on 23 August 2014

Barbie 184 Tibolone is just a synthetic, artificial estrogen product mixed with prosestin. You can change to a real bioidentical hormone patch like the vivelle dots. This would be the same if not better. You would also need a prescription of progesertone if you wanted to duplicate the Tibolone. Progesterone is given to mitigate against an estrogen imbalance. My mother had bad osteoporosis and she was given estrogen but it was to late in her life to adequately benefit from hormone replacement. She always says she wised she would have taken it but was discouraged by a doctor at an HMO. It is thought medically that hormone replacement staves off osteoporosis. And this is the usual medical treatment given.

Zombie CS said on 18 August 2014

I am in remission for PMR but I still have practically the same pain everywhere – neck, arms, wrists, hips, ankles.
Have others suffered like this? If so, for how long?

Barbie148 said on 16 July 2014

Interesting to read others stories..I have temporal artritis for over 4 years, and 16 months ago, developed polymyalgia. I have in the last few years, had 2 hip replacements and one knee replacement….I have osteoporosis quite badly, affecting bones. I have lost bottom teeth, and gums receded badly, still trying to sort..had gum trouble since teenager, now nearly 80! I am on steroids, and lots of other medication….the heat is just too much at the moment, and legs and feet swollen. I have also been on Tibolone for well over 24 years now, but recently doctors have insisted I come off it, and the hospital have said also…I did not want to, now life is not quite the same, also, since I stopped Tibolone about 3-4 months ago, severe pains have come back in my shoulder and neck, and waist, and hips….waist is out of shape now….I am sure this is due to not takingTibolone, as I read it is also helpful to stop bone troubles, and osteoporosis, and osteoarthritis….I so wish I could still be on Liivial/Tibolone, but told repeat prescription for it will not be made! But then they are considering my age, and side affects. A few years ago a very good consultant professor said I could stay on Tibolone indefinitely….she has now retired, and I cannot get hold of her anymore….I do have her letter to say that, but no one takes any notice of it.
So still have to struggle on, and I am convinced these pains coming like this is due to me stopping Tibolone.
Any suggestions most welcome..

anahera said on 13 July 2014

I have had polymyalgia for around 18 months now. I am on steroids and started at 15mg they affected me badly. At first it was like a wonder drug. Pain free and i was able to live normally. But soon I had developed Moonface. Cushing’s syndrome. Weight gain. Depression very bad. And tore my calf muscle just walking. I am now on 9 mg and it has been gradual coming down. All my symptoms came rushing back. I can hardly move some days. My stiffness is not just mornings. Pain is constant. I researched natural remedies and am taking a turmeric (curcumen) capsule twice a day. Turmeric us reputed to help with anti inflammatory and also with pain. It helps a bit. I also made golden milk using turmeric powder. On you tube. It helped me to sleep better. But it is still an ongoing struggle. But I have learned not to feel guilty at not being able to do things as before. I listen to my body and rest when I have to as well.

Mysayso said on 30 March 2014

My PPMR has been treated since July 20123 with Prednisalone injections approximately every 12 weeks. Yesterday I was boasting that it had burnt itself out as I had no symptoms. Ho! Ho! I woke up this morning with swollen hands also painful and stiff and very cranky knees. So back to the rheumatologist again I fear.

Sub80 said on 27 March 2014

My friend has been diagnosed with this condition,3 months after starting to take statins,is there a connection?

CJMorny said on 18 September 2013

I have been told that it is likely that I have Fibromyalgia but the fever and pain in the hips that I get in addition to other pain makes me think it is more likely to be polymialgia. This would be a relief as at least there seems to be treatment for it.

User163496 said on 30 July 2013

Ive just been diagnosed with Pmr after being in constant pain for a few years. I do work but first thing in a morning i really do struggle to get out of bed and get started. Somedays its so bad i dont want to go in and feel like quitting but i push myself and go. the doctor has prescribed me an anti inflam which having read the posts seems unusual, im trying to loose weight so maybe thats why. Its good to finally know whats wrong with me after all this time.

triciam said on 18 June 2012

I was diagnosed with PMR in November 2011 and have been on various doses of Prednisalone since then. The lower the dose the worse the pain. I recently had to have a routine eye test and have been referred to local eye clinic as optician thought retinal dterioration was related to PMR. My biggest worry is the effect the predinisalone is having on my bones. In 2010 I had to have a hip replacement, originally from 1979, re-done as the old prosethis had worked its way through the femur leaving a hole. Consequently I now have a long stem prosthesis which reaches almost to my knee. The bone graft done at the time didn’t work too well and bone growth has been minimal. I take a weekly Alendronic Acid tablet to slow down bone deterioration from the steroids but I’m sure that I’m risking damage to the femur and hip joint with continued use of steroids. Another problem is that strong pain killers cause violent vomitting so I’m limited to paracetamol and ibuprofen.

spyvee24 said on 08 March 2012

my husband had problemswith severe pains and after many times of visiting gp he was started on prednisolone with amazing results within 48hrs, he became a new man. the gp reduced the dose over a couple of months, the lower the dose the pains started to return but no where near what they were to start with, but the gp has stopped the prednisalone and is referring him to a rheumatologist and now my husband feels he has been left to be in pain and it is worsening by the day, we are worried that it is going to return to the severity it was when he could sometimes not even turn over in bed. he cannot afford to start turning work down again. it is very distressing to see him like this and we do not know whetrher he is just going to have to live with it. it does not seem right to be laeft like this

dorron said on 14 February 2011

i have so iam to believe pmr/osteo my treatment for the past 4years,is prednisolone and at present methotresate 10×2,5mg together over the years the steroid has affected my eyesight.at present my dose of this steroid is 2mg.in the past few weeks i have tried to reduce this steroid to 2 and 1 on alternative days,within 1 week all the problems returned,ie shoulders,swollen hands,cannot grip anything,and to top it all both my knees have got worse.proving that taking methetresate ahs no affect at all.has anybody else had these problems

havfruen said on 29 October 2010

I was diagnosed with PMR in September 2001 and suffered really badly for 6 years even though prednisolone helped a great deal. I was eventually weaned off the prednisolone and managed on prescribed painkillers and anti-inflammatory tablets for a while. They however gave me a bad stomach so I eventually had to come off them. This has unfortunately resulted in another flare up of the PMR and I am now suffering worse than before. I really do not want to go back on the Prednisolone. Any other suggestions?

Alfreda70 said on 07 June 2010

I have had PMR for 4 years and am currently on a low dose of prednisalone. I have experienced dramatic reduction in pain and stiffness after eating pineapples. I have tried to navigate my way through the internet but find so much information it is difficult to understand. Has any research been done into the effects of bromelain on PMR?

I have CKD level 3 and have read that one should not take bromelain in this situation and also that it should not be taken for more than 2 weeks. has anyone any information on this, please?

Tomargan said on 18 April 2010

i have had this gca and pmr for the last year it is very a debhlitating, nasty thing to have got. my life has changed a lot, so much pain, i was taking steroids but am off them at present, as they allowed too much fluid to collect in my legs and now they are inflammed, i take morphine for the pain i am having. there seems nbo end to it all.

pat16 said on 10 February 2010

I have suffered from chronic Fibromyalgia for about 12 years now. I take over 20 tablets per day most of which are pain killers. From time to time I have had bad relapsed which leave me vertually helpless for a few days and then I pick up a little and can do light tasks working at my own pace. Lately the pain as been getting worse and I have just been diagnosed with PMR. Apparently the only way to be sure is to have an ESR blood test as this is the only thing that shows it up.

maxamillion said on 18 June 2009

one question regarding PMR and GCA. I have been diagnosed with PMR, my Doctor gave me tablets for my shoulder pain. He told me to watch out for any signs of vision problems and to contact him. Now that i have read the above info on PMR, i have discovered that GCA is related to PMR with the possible vision problem that may occur as stated. I am a bit concerned about this and how can i be sure that i do have PMR? Are these steroid tablets that neccessary for me to take if i don’t have GCA.

Useful links

NHS Choices links

External links

var hu_webpart_id = 2;
var hu_comm_id = 44;

var huarr = huarr || [];
huarr.push([‘_createWebpart’, hu_webpart_id + ‘,’ + hu_comm_id]);
(function () {
var hu = document.createElement(‘script’);
hu.id = ‘hu_webpartid’ + hu_webpart_id;
hu.type = ‘text/javascript’; hu.async = true;
hu.src = (‘https:’ == document.location.protocol ? ‘https://’ : ‘http://’) + ‘www.healthunlocked.com/choices.v6.js’;
var s = document.getElementsByTagName(‘script’)[document.getElementsByTagName(‘script’).length – 1]; s.parentNode.insertBefore(hu, s);
})();

Community content from HealthUnlocked

Neck pain or a stiff neck

Neck pain or stiffness is often nothing to worry about. Here’s how to manage it at home

Women’s health 60-plus

Healthy lifestyle information and advice for women aged 60 and over

(function (i, s, o, g, r, a, m) {
i[‘GoogleAnalyticsObject’] = r; i[r] = i[r] || function () {
(i[r].q = i[r].q || []).push(arguments)
}, i[r].l = 1 * new Date(); a = s.createElement(o),
m = s.getElementsByTagName(o)[0]; a.async = 1; a.src = g; m.parentNode.insertBefore(a, m)
})(window, document, ‘script’, ‘//www.google-analytics.com/analytics.js’, ‘ga’);

ga(‘create’, ‘UA-9510975-1’, ‘www.nhs.uk’);
ga(‘require’, ‘displayfeatures’);
ga(‘send’, ‘pageview’);

//

//

NHS Choices Syndication

table.options
{
border-spacing: 0px;
margin-top: 1em;
}
table.options, table.options th, table.options td
{
border: solid 1px black;
}
table.options th, table.options td
{
padding: 5px 5px 5px 5px;
}
dl.links dt
{
font-weight: bold;
}

Representations

/conditions/articles/polymyalgia-rheumatica/diagnosis

Polymyalgia rheumatica

Diagnosing polymyalgia rheumatica

[Original article on NHS Choices website]

Diagnosing polymyalgia rheumatica (PMR) can often be quite a lengthy process that involves several different tests.

This is because the condition shares many symptoms with more common health conditions, such as rheumatoid arthritis, which need to be ruled out first.

Tests

It is likely that a series of blood tests will be carried out.

Blood tests called erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) are usually used to check the levels of inflammation in your body.

Blood tests can also determine:

whether there is an infection in your blood
how well some of your organs, such as your kidneys, are working
whether you have an overactive thyroid gland or an underactive thyroid gland (both conditions can cause muscle pain)

You may also have a urine test to check how well your liver is functioning, as well as X-rays and ultrasound scans to assess the condition of your bones and joints.

Symptom checklist

After other possible causes of your symptoms have been ruled out, a checklist can be used to see whether your symptoms match those most commonly associated with polymyalgia rheumatica.

According to the most widely used checklist, a very confident diagnosis of polymyalgia rheumatica can be made if you meet all of the following criteria:

you are over 50 years old
you have pain in your shoulders or your hips
you have stiffness in the morning that lasts longer than 45 minutes
your symptoms have lasted longer than two weeks
blood tests show raised levels of inflammation in your body
your symptoms improve rapidly after being treated with corticosteroids (see treating polymyalgia rheumatica for more information)

Useful Links

Published Date: 2014-04-10 15:58:38Z
Last Review Date: 2013-01-28 00:00:00Z
Next Review Date: 2015-01-28 00:00:00Z

Classification: Giant cell arteritis,Polymyalgia rheumatica

NHS Choices Syndication

table.options
{
border-spacing: 0px;
margin-top: 1em;
}
table.options, table.options th, table.options td
{
border: solid 1px black;
}
table.options th, table.options td
{
padding: 5px 5px 5px 5px;
}
dl.links dt
{
font-weight: bold;
}

Representations

/conditions/articles/polymyalgia-rheumatica/introduction

Polymyalgia rheumatica

Introduction

[Original article on NHS Choices website]

Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.

Polymyalgia rheumatica may also cause other symptoms, including:

a high temperature (fever)
extreme tiredness (fatigue)
loss of appetite
weight loss
depression

If you have pain and stiffness that lasts longer than a week, you should see your GP so the cause can be investigated.

It can be difficult to diagnose polymyalgia rheumatica because it has symptoms similar to many other conditions, such as rheumatoid arthritis. These conditions will need to be ruled out before polymyalgia rheumatica is diagnosed.

Read more about the symptoms of polymyalgia rheumatica and diagnosing polymyalgia rheumatica.

How is it treated?

The main treatment for the condition is a steroid medication (corticosteroids) called prednisolone, which is used to help relieve your symptoms.

You will initially be prescribed a high dose of prednisolone, which will be reduced gradually over time.

Most people with polymyalgia rheumatica will need to take a long-term course of corticosteroid treatment (lasting one to two years) to prevent their symptoms returning.

Read more about treating polymyalgia rheumatica.

Who is affected?

Polymyalgia rheumatica is relatively common in the UK. It is estimated that one in every 1,200 people develop the condition every year.

Polymyalgia rheumatica is an age-related condition. Most people diagnosed with the condition are over 70 years old and cases affecting people younger than 50 are almost unheard of.

The condition is two to three times more common in women than men. It is more widespread among white people, particularly those of northern European descent.

The cause of polymyalgia rheumatica is unclear. However, it is thought that a combination of genetic and environmental factors is responsible.

Useful Links

Published Date: 2014-04-10 15:55:37Z
Last Review Date: 2013-01-28 00:00:00Z
Next Review Date: 2015-01-28 00:00:00Z

Classification: Giant cell arteritis,Polymyalgia rheumatica

NHS Choices Syndication

table.options
{
border-spacing: 0px;
margin-top: 1em;
}
table.options, table.options th, table.options td
{
border: solid 1px black;
}
table.options th, table.options td
{
padding: 5px 5px 5px 5px;
}
dl.links dt
{
font-weight: bold;
}

Representations

/conditions/articles/polymyalgia-rheumatica/mapofmedicinepage

Polymyalgia rheumatica

See what the doctor sees with Map of Medicine

[Original article on NHS Choices website]

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK’s leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: polymyalgia rheumatica

Map of Medicine: temporal arteritis

Useful Links

Published Date: 2011-09-11 18:11:01Z
Last Review Date: 2009-03-19 00:00:00Z
Next Review Date: 2011-03-19 00:00:00Z

Classification: Giant cell arteritis,Polymyalgia rheumatica

NHS Choices Syndication

table.options
{
border-spacing: 0px;
margin-top: 1em;
}
table.options, table.options th, table.options td
{
border: solid 1px black;
}
table.options th, table.options td
{
padding: 5px 5px 5px 5px;
}
dl.links dt
{
font-weight: bold;
}

Representations

/conditions/articles/polymyalgia-rheumatica/symptoms

Polymyalgia rheumatica

Symptoms of polymyalgia rheumatica

[Original article on NHS Choices website]

The most common symptom of polymyalgia rheumatica (PMR) is pain and stiffness in the shoulder muscles which develops quickly over a few days or weeks.

The muscles in the neck and hips are also often affected.

You may only notice pain and stiffness in one side of your body at first, but both sides are usually affected as the condition progresses.

The stiffness usually feels worse first thing in the morning after you wake up and starts to improve after about 45 minutes as you become more active.

Some people with polymyalgia rheumatica have additional symptoms, including:

a mild high temperature (fever) of 37-38°C (98.6-100.4°F)
depression
fatigue (extreme tiredness)
loss of appetite
weight loss

When to seek medical advice

If you have symptoms of pain and stiffness that last longer than a week, you should make an appointment to see your GP so that the cause can be investigated.

When to seek immediate medical advice

You should seek immediate medical advice if you have been diagnosed with polymyalgia rheumatica (or the condition is suspected) and you suddenly develop:

a persistent and severe headache
jaw pain or cramping in your jaw muscles which is worse when you are eating
vision loss or vision disturbances, such as double vision

These symptoms may indicate a more serious condition called giant cell arteritis (temporal arteritis).

If you have any of the above symptoms, call your GP immediately for advice. If this is not possible, call NHS Direct on 0845 46 47 or contact your local out of hours service.

Useful Links

Published Date: 2013-06-13 10:07:04Z
Last Review Date: 2013-01-28 00:00:00Z
Next Review Date: 2015-01-28 00:00:00Z

Classification: Aches, pains and soreness,Appetite loss,Giant cell arteritis,Polymyalgia rheumatica

NHS Choices Syndication

table.options
{
border-spacing: 0px;
margin-top: 1em;
}
table.options, table.options th, table.options td
{
border: solid 1px black;
}
table.options th, table.options td
{
padding: 5px 5px 5px 5px;
}
dl.links dt
{
font-weight: bold;
}

Representations

/conditions/articles/polymyalgia-rheumatica/treatment

Polymyalgia rheumatica

Treating polymyalgia rheumatica

[Original article on NHS Choices website]

Steroid medication (corticosteroids) is the preferred treatment for polymyalgia rheumatica (PMR). A type of corticosteroid called prednisolone is usually prescribed.

Prednisolone

Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It does not cure polymyalgia rheumatica, but it can help relieve the symptoms.

When used to treat polymyalgia rheumatica, prednisolone is taken orally. Most people will be prescribed several tablets to take once a day.

You will be prescribed a high dose of prednisolone initially and the dosage will be gradually reduced every one to two months.

Although your symptoms should improve significantly within a few days of starting your treatment, you will probably need to continue taking a low dose of prednisolone for about two years.

In many cases, polymyalgia rheumatica improves on its own after this time. However, there is a chance that the condition will return (relapse) once treatment stops.

Do not suddenly stop taking steroid medication, unless told by a doctor that it’s safe to do so. Suddenly stopping treatment with steroids can make you feel very ill.

Side effects

About one in 20 people who take prednisolone will experience changes in their mental state when they take the medication.

For example, you may feel very depressed and suicidal, very anxious or very confused. Some people also experience hallucinations (feeling, seeing or hearing things that are not there). Contact your GP as soon as possible if you experience changes to your mental state.

Other side effects of prednisolone include:

increased appetite that often leads to weight gain
increased blood pressure
mood changes, such as becoming aggressive or irritable with people
weakening of the bones (osteoporosis)
stomach ulcers
increased risk of infection, particularly the virus that causes chickenpox and shingles (varicella-zoster virus)

Seek immediate medical advice if you think that you have been exposed to the varicella-zoster virus or if a member of your household develops chickenpox or shingles.

The risk of these side effects should improve as your dosage of prednisolone is decreased.

See side effects of corticosteroids for more information about how these side effects may affect you and how they are treated.

Other medications

Sometimes, other medications may be combined with corticosteroids to help prevent relapses or to allow your dose of prednisolone to be reduced.

Some people are prescribed immunosuppressant medication, such as methotrexate. This is used to reduce or suppress the immune system (the body’s defence against illness and infection). It may be helpful for people with polymyalgia rheumatica who have frequent relapses or don’t respond to normal steroid treatment.

Your doctor may recommend painkillers such as paracetamol to help relieve pain while your dose of prednisolone is reduced.

Follow-up

Your GP will ask you to attend regular follow-up appointments so they can check how well you are responding to treatment, whether your dosage of prednisolone needs to be adjusted, and how well you are coping with the side effects of the medication.

During these appointments, you will have blood tests to check the levels of inflammation inside your body.

Follow-up appointments are usually recommended every few weeks for the first three months and then at three- to six-monthly intervals after this time.

If you experience a return of your symptoms during any part of your treatment, contact your GP as your dosage may need to be adjusted.

Useful Links

Published Date: 2013-06-13 09:56:58Z
Last Review Date: 2013-01-28 00:00:00Z
Next Review Date: 2015-01-28 00:00:00Z

Classification

jQuery(document).ready(function() {
jQuery( “#tabs” ).tabs();
});

Leave a Reply Cancel reply