Updated EULAR guidelines on polymyalgia rheumatica (PMR) and large vessel vasculitis (LVV) position targeted biologic agents as first-line options for patients with refractory, relapsing or high-risk disease.
Presenting the recommendations at the congress, Dr Chetan Mukhytar from Norfolk and Norwich University Hospitals NHS Foundation Trust said the updated guidance sets out a more structured role for biologic therapies in both PMR and giant cell arteritis (GCA), particularly where glucocorticoid toxicity or treatment failure is a concern.
In PMR, IL-6 receptor inhibitors may now be used as adjunctive therapy in selected patients. Tocilizumab is recommended for new-onset disease, while sarilumab is preferred for relapsing or refractory PMR, with tocilizumab as an alternative. Methotrexate is highlighted as an adjunctive option across both groups.
“We have clinical trial evidence demonstrating that tocilizumab works in these patients,” Dr Mukhytar said. “It is intended for situations where you instinctively feel glucocorticoids are not in the patient’s best interest, or where you must minimise the steroid dose.”
In GCA, tocilizumab or upadacitinib should be considered as adjunctive therapy, especially in refractory or relapsing disease or where glucocorticoid-related adverse effects are a concern. Clinicians are advised to follow current safety guidance when choosing between agents. Methotrexate remains an alternative.
For new-onset GCA or newly diagnosed active Takayasu arteritis (TAK), glucocorticoids are recommended for induction of remission at 40–60 mg/day, tapering to 15–20 mg/day within two to three months, with the aim of stopping within 12–18 months.
Suspected GCA should be treated with glucocorticoids immediately while awaiting confirmatory tests, reflecting its status as a medical emergency. In most cases of suspected PMR or TAK, treatment can be delayed until diagnosis is confirmed.
Patients with suspected GCA should be referred urgently and seen by a specialist within 24 hours, the guidelines state.
Dr Mukhytar noted that relapse in PMR and GCA should be identified on the basis of clinical signs, symptoms and laboratory markers, supported by imaging where necessary. In TAK, imaging plays a more central role alongside clinical and laboratory assessment.
“Patients with GCA may present with completely new symptoms during a relapse, sometimes involving entirely different arterial territories,” he said. “GCA can also relapse as PMR, and PMR can relapse as GCA.”
Recommendations for TAK were largely unchanged due to a lack of new evidence.
The guidelines also address refractory disease management, surgical and endovascular interventions, and patient follow-up and monitoring.
Overarching principles
Four overarching principles underpin the guidance. These place shared decision-making at the heart of care, recommend imaging or biopsy to confirm suspected GCA and TAK rather than reliance on classification criteria alone, and call for structured patient education on disease impact and treatment risks. Routine screening for cardiovascular and treatment-related comorbidities is also emphasised.
Dr Mukhytar noted that the 2025 recommendations achieved high consensus across an international task force including experts from 13 European countries as well as Canada, the United States and India. The full systematic literature review and treatment algorithms will be published in RMD Open.