Summary

The 2026 updated recommendations from the German, Austrian and Swiss rheumatology societies reaffirm glucocorticoids (15–25 mg prednisone equivalent daily) as the cornerstone of initial treatment for polymyalgia rheumatica (PMR), with subsequent tapering guided by disease activity, laboratory parameters and treatment-related adverse events. A major update compared with the 2018 recommendations is the incorporation of interleukin-6 receptor (IL-6R) inhibitors as the preferred glucocorticoid-sparing strategy. IL-6R blockers (tocilizumab and sarilumab) should be considered in patients with relapsing PMR and may also be used in selected patients with newly diagnosed disease who are at high risk of glucocorticoid-related complications. Based on expert opinion, the guideline recommends a maximum glucocorticoid duration of 1 year with monotherapy, approximately 6–8 months with methotrexate, and only 16 weeks when combined with a biologic agent. The recommendations additionally emphasize early rheumatology referral, individualized risk stratification, shared decision-making, and tailored exercise programs for elderly and frail patients.

Clinical impact

The most important clinical implication of these updated recommendations is the shift from methotrexate to IL-6R inhibition as the preferred glucocorticoid-sparing approach in selected patients. Methotrexate is now considered an alternative option rather than the first-choice adjunctive therapy. Randomized controlled trials have consistently shown higher remission rates and lower cumulative glucocorticoid exposure with tocilizumab and sarilumab compared with placebo. As a result, clinicians now have evidence-based options for patients with relapsing disease and for those at increased risk of glucocorticoid toxicity, such as individuals with diabetes, osteoporosis or cardiovascular comorbidities. Glucocorticoids nevertheless remain the first-line therapy for all patients,  but clinicians now also have more clearly defined guidance on glucocorticoid treatment duration when methotrexate or biologic therapy is used.

Future Perspectives

Several important research directions emerge from these recommendations. First, additional studies are required to identify reliable prognostic markers that predict relapse risk and treatment response. Second, optimal glucocorticoid tapering regimens and treatment duration remain insufficiently defined. Third, comparative trials between IL-6R inhibitors, methotrexate and combination strategies are needed to determine the most effective and cost-efficient treatment algorithms. Emerging data on Janus kinase (JAK) inhibitors, particularly tofacitinib and baricitinib, are promising and may further expand therapeutic options in PMR. Leflunomide is also being investigated in ongoing clinical trials.

References:

1.  Buttgereit F, Boyadzhieva Z, Reisch M, et al. Recommendations of the German, Austrian and Swiss rheumatology and other medical societies for the management of polymyalgia rheumatica. Rheumatology (Oxford). 2026 Feb 4;65(2):keaf646. doi: 10.1093/rheumatology/keaf646. PMID: 41346249.

Composed by

Dr. med. Andrea Gloor,  Department of Rheumatology and Immunology, Inselspital Bern