Impact on Patient Treatment and Future Perspectives

Diagnosis and treatment: All patients with suspected PMR, GCA or TAK should be referred for specialist assessment; patients with a strong suspicion of GCA should be referred within 24 hours. In patients with a definite suspicion of GCA, treatment with glucocorticoids (GCs) should be started immediately, using 40 to 60 mg of prednisone. In most patients with suspected PMR or TAK, treatment with GCs can be deferred until the diagnosis is confirmed. To induce remission, GCs should be administered at a dose of 15 to 25 mg/day prednisone equivalent for PMR and 40 to 60 mg for GCA or TAK. In specific cases (e.g. ocular involvement), high-dose GC administration, e.g. 250–500 mg intravenously over 3 days, should be considered.

In selected patients with GCA, adjunctive therapy is recommended, either with interleukin (IL)-6 receptor inhibitors or with upadacitinib. Methotrexate may be an alternative (note: off-label).

In all patients with TAK, GC-sparing agents should be administered in combination with GC.

New for PMR: an IL-6 receptor antagonist is recommended as a steroid-sparing therapy:

•   Tocilizumab: particularly in selected patients with newly diagnosed PMR

•   relapsing/refractory PMR: sarilumab is preferred, with tocilizumab as an alternative

•   Methotrexate remains an alternative. (Note: all three substances are used ‘off-label’        for PMR in Switzerland)

This recommendation is now supported by randomised trials. For example, the SAPHYR trial in patients with relapsing PMR showed a higher rate of sustained remission with sarilumab than with placebo (28% vs. 10%) and a significant reduction in steroid use.

The practical implication for a patient with PMR who has:

•    repeated relapses,

•    steroid dependence,

•    high cumulative steroid exposure, or

•    a high risk of steroid-related complications

is that MTX is no longer the sole traditional steroid-sparing option; instead, the focus has shifted significantly towards IL-6R inhibition

Key message of the new guidelines compared with the old guidelines:

The most significant paradigm shift can be summarised as follows:

A move away from primarily glucocorticoid-based treatment towards an individualised, steroid-sparing strategy with earlier use of targeted therapies in suitable patients.

Glucocorticoids remain the main initial treatment, but the new treatment goal is explicitly to achieve remission with as little glucocorticoid use as possible. At the same time, diagnosis, prompt referral to a specialist, imaging, detection of relapse and long-term monitoring are becoming more structured.

The most important change is therefore not necessarily the GC dose, but the therapeutic strategy:

The previous guideline from 2015/2018 was essentially as follows:

-   Glucocorticoids → slow tapering → MTX/tocilizumab in selected cases if problems     arise.

The new guideline takes a more focused approach:

-   definite diagnosis → early referral to a specialist → the lowest possible individual steroid dose → early steroid-sparing targeted therapy in suitable patients → glucocorticoid-free remission where possible → structured long-term monitoring.

In particular, the increased emphasis on IL-6 receptor blockade for PMR (note: still not authorised in Switzerland) and the introduction of upadacitinib as an option for GCA (note: still not included in the guidelines as of August 2026) are the most clinically relevant developments with regard to medication.

References:

Mukhtyar CB, Nikiphorou E, Bartoletti A, Dey M, Ducker G, Misra DP, Monti S, Studenic P, Berti A, Blockmans D, Brouwer E, Buttgereit F, Cannings K, Cid MC, Conway R, Christ L, Dejaco C, Keller KK, Kingham L, Merkel PA, Mohammad AJ, Mollan SP, Nielsen BD, Ponte C, Saadoun D, Schmidt WA, Warrington KJ, Hellmich B. 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis. Ann Rheum

Composed by

PD Dr. med. Christof Iking-Konert, Stadtspital Zürich