Updated British guidance recommends earlier rheumatology referral after relapse, faster steroid tapering in selected patients and greater consideration of steroid-sparing therapies to reduce the harms of prolonged glucocorticoid treatment.
The British Society for Rheumatology has updated its polymyalgia rheumatica treatment guidelines for the first time since 2009, recommending earlier specialist involvement and greater consideration of methotrexate and IL-6 receptor inhibitors in selected patients.
The updated guidance reflects emerging evidence on treatment options for polymyalgia rheumatica (PMR), particularly for patients who relapse during glucocorticoid tapering or experience adverse effects from prolonged treatment.
Glucocorticoids remain the cornerstone of PMR management, but the guideline places greater emphasis on individualised treatment, reducing cumulative steroid exposure and identifying patients who may benefit from alternative therapies.
The guidance has been published in Rheumatology this month.
“This guideline is intended for health professionals who are involved in the care of people with PMR, including general practitioners, rheumatologists, nurses, pharmacists, physiotherapists and other allied health professionals,” the researchers wrote.
“It may also be informative for patient groups and patient support organisations.”
The recommendations apply to patients with confirmed PMR and provide practical advice on glucocorticoid initiation, tapering and monitoring, as well as thresholds for discussion with or referral to rheumatology.
For newly diagnosed PMR, the guideline recommends starting prednisolone at 12.5–15mg daily, increasing to a maximum of 25mg if required for symptom control.
Once symptoms have been controlled for two to four weeks, clinicians should begin tapering prednisolone by 2.5mg every two to four weeks until reaching 10mg daily, followed by reductions of 1mg every four to eight weeks.
However, the guideline acknowledged that tapering schedules must be individualised according to disease activity, comorbidities, and the risk of treatment-related complications.
In patients at high risk of glucocorticoid toxicity, clinicians could consider a faster taper once disease activity was controlled, reducing prednisolone by 1mg every two to three weeks with the aim of discontinuing treatment within six months.
This approach required closer monitoring for relapse and adrenal insufficiency, particularly when prednisolone doses fall below 5mg daily, the researchers noted.
The guideline stated that glucocorticoid treatment often continues considerably longer than anticipated. UK primary care data suggest that patients discontinue continuous treatment after a median of 1.31 years, while the median total duration of glucocorticoid exposure, accounting for treatment restarts, approaches two years.
Relapse remained a major challenge, affecting up to two-thirds of patients with PMR and frequently extending the duration of glucocorticoid treatment.
For patients who relapsed, the guideline recommended returning to the last effective prednisolone dose for two to four weeks before considering a slower taper.
Related
Clinicians should also reassess the diagnosis and investigate alternative explanations for recurrent symptoms, including giant cell arteritis (GCA), infection, malignancy, mechanical musculoskeletal disease, and adrenal insufficiency.
One of the key changes was the recommendation to consider rheumatology input earlier following relapse, rather than waiting until patients have experienced prolonged glucocorticoid exposure.
The guideline specifically recommended referral to rheumatology after two relapses.
It also supported earlier consideration of methotrexate, including discussing the option of rheumatology referral with newly diagnosed patients to consider adding the drug to glucocorticoid therapy.
Methotrexate may be particularly appropriate for patients at increased risk of glucocorticoid toxicity or those who have already relapsed.
However, the researchers noted that treatment decisions should account for renal function, frailty, comorbidities, and potential adverse effects, with regular monitoring for hepatotoxicity and bone marrow suppression.
The guideline also recommended considering IL-6 receptor antagonists alongside glucocorticoids in patients who had an inadequate response to steroids or could not tolerate glucocorticoid tapering.
The recommendation reflected growing evidence supporting IL-6 inhibition as a steroid-sparing strategy in difficult-to-treat PMR, although treatment selection should consider individual patient risks and the need for specialist supervision.
Guideline Working Group co-chair Dr Max Yates said the recommendations incorporated new evidence and a more rigorous development process than the previous guidance.
“Our previous guideline, published in 2009, predated BSR’s current framework for guideline development,” he said.
“These updated recommendations draw on new evidence and have been developed using that robust framework, giving clinicians a strong evidence base to support treatment decisions in PMR.”
PMR is a common inflammatory rheumatic condition affecting older adults, typically presenting with bilateral shoulder and hip girdle pain and stiffness.
Although glucocorticoids generally produce a rapid clinical response, relapse during dose reduction remains a significant challenge, while prolonged treatment increases the risk of complications including osteoporosis, fractures, diabetes, and infection.
The updated recommendations emphasised the importance of monitoring for glucocorticoid toxicity and implementing appropriate bone protection strategies throughout treatment.
In a stronger approach to fracture prevention, the guideline recommended prescribing bisphosphonates to patients starting glucocorticoid therapy unless contraindicated, with specialist advice on alternative bone protection where necessary.
They also highlighted shared decision-making and patient education, particularly helping patients recognise symptoms of relapse, treatment-related adverse effects and possible GCA.
The guideline cautioned that inflammatory markers alone may not reliably distinguish relapse from other causes of symptoms, particularly during glucocorticoid treatment.
Patients experiencing recurrent pain or stiffness during tapering should undergo clinical reassessment, with C-reactive protein or erythrocyte sedimentation rate measurements used to support, rather than replace, clinical judgement.
The possibility of adrenal insufficiency should also be considered in patients developing symptoms during low-dose prednisolone tapering, particularly when inflammatory markers remained normal.
The guideline was developed by a multidisciplinary working group comprising rheumatologists, general practitioners, nurses, pharmacists, physiotherapists, researchers, and people with lived experience.
Its recommendations were intended to support treatment decisions across primary and secondary care, with particular emphasis on identifying when specialist assessment may improve outcomes.
The guideline has been endorsed by the Primary Care Rheumatology and Musculoskeletal Medicine Society and the Royal College of General Practitioners, supporting its implementation across general practice and specialist services.
