EULAR released the 2025 recommendations to establish clear pathways for the management of polymyalgia rheumatica and large vessel vasculitis.
The European Alliance of Associations for Rheumatology (EULAR) has released its updated 2025 recommendations for managing polymyalgia rheumatica (PMR) and large vessel vasculitis (LVV), which includes giant cell arteritis (GCA) and Takayasu arteritis (TAK).
Presented at the EULAR 2026 Annual Meeting in London by co-convener Associate Professor Chetan Mukhtyar, a rheumatologist at Norfolk and Norwich University Hospitals NHS Foundation Trust, in the UK, representing a 13-country international task force, the guidelines integrate fresh systematic review data to help clinicians navigate complex phenotypes.
The recommendations were built upon three core overarching principles, Professor Mukhtyar said.
First, clinicians must seek their patients’ active participation in all management decisions, weighing efficacy, safety, and costs.
Second, formal diagnosis must be based on clinical signs and confirmed via imaging or histology, explicitly discouraging the use of classification criteria for diagnostic purposes.
Lastly, patients require structured education regarding disease complications, alongside rigorous screening for cardiovascular comorbidities to mitigate the heavy impact of lifetime glucocorticoid burden.
The 2025 management recommendations
Recommendation 1: Specialist referral pathways
All patients with suspected PMR, GCA, or TAK require rapid referral to a specialist with appropriate expertise. If cranial GCA is suspected, this referral is considered an absolute medical emergency and must occur within 24 hours of presentation. PMR has been purposefully added to this urgent specialist directive due to primary care data indicating the disease is frequently under-investigated, over-diagnosed, or masking hidden vascular involvement.
Recommendation 2: Glucocorticoid initiation
When clinical suspicion of GCA is high, treatment with systemic glucocorticoids must be initiated immediately, without awaiting confirmatory results. Conversely, for the majority of patients with suspected PMR or TAK, glucocorticoid initiation can safely be delayed until objective diagnostics are completed. Clinicians are strongly discouraged from using a trial of glucocorticoids as a proxy diagnostic test.
Recommendation 3: Glucocorticoid dosing in PMR
For patients with new-onset PMR, oral glucocorticoids should be initiated for remission induction at 15-25mg per day, followed by a gradual taper to 10mg per day within the first two months. The ultimate target is to successfully cease steroid therapy within one year. If a patient relapses, therapy should be escalated back to the last effective individual dose.
Recommendation 4: Glucocorticoid dosing in GCA
New-onset GCA patients should start oral glucocorticoids at an initial dose of 40-60mg per day. This should be systematically tapered to 15 to 20mg by months two to three, aiming for complete cessation within 12 to 18 months. Major relapses involving ischemic events or structural arterial changes require immediate re-escalation back to full induction doses.
Recommendation 5: Glucocorticoid dosing in TAK
Active TAK requires a similar initial oral glucocorticoid strategy of 40 to 60mg daily, tapered to 15 to 20mg within two to three months, with the same target of stopping treatment within 12 to 18 months. Minor relapses across all indications should be managed by returning to the last effective maintenance dose.
Recommendation 6: Adjunctive therapy choices in PMR
To minimise systemic steroid toxicity, adjunctive therapy using the interleukin-6 receptor (IL-6r) inhibitor tocilizumab can be considered for select patients with new-onset PMR. For relapsing or refractory PMR, alternative IL-6r options such as sarilumab are preferred, while methotrexate remains a viable, familiar alternative if access to biologics is restricted. Clinicians can utilise these steroid-sparing agents early if a patient has neuropsychiatric issues, fragile diabetes, or severe heart failure.
Recommendation 7: Adjunctive therapy choices in GCA
Advanced adjunctive therapies using either tocilizumab or the JAK inhibitor upadacitinib should be actively considered for GCA patients, particularly those with refractory disease or those facing a steep risk of steroid-related adverse events. Clinicians are advised to carefully weigh the localised safety profiles of both agents, utilising methotrexate as an acceptable alternative strategy.
Recommendation 8: Adjunctive therapy choices in TAK
All patients diagnosed with TAK should receive adjunctive therapy utilising non-biologic disease-modifying agents from the outset. If the disease becomes refractory or relapses despite conventional DMARD usage, escalating the treatment plan to include tocilizumab or TNF inhibitors is recommended.
Related
Recommendation 9: Diagnosing disease relapse
Identifying relapse in PMR and GCA should rely heavily on evolving clinical signs, laboratory markers, and imaging when necessary. However, diagnosing a relapse in TAK relies heavily on serial imaging and laboratory evaluations. Clinicians must remain vigilant, as GCA relapses can manifest in entirely new arterial territories or masquerade interchangeably as PMR.
Recommendation 10: Managing refractory disease
Any patient exhibiting true refractory PMR, GCA, or TAK requires an immediate, comprehensive re-evaluation of their initial diagnosis. These individuals should be considered for prompt referral to a tertiary specialist centre, as refractory presentations often represent underlying malignancies, alternative inflammatory arthritides, or distinct vascular conditions such as Buerger’s disease.
Recommendation 11: Surgical and endovascular interventions
Elective reconstructive surgeries or endovascular procedures for GCA and TAK patients must only be performed during phases of stable, documented disease remission. However, acute arterial vessel dissections or critical vascular ischemia represent surgical emergencies requiring immediate referral to a vascular team. The choice of technique should take into account that open interventions offer better long-term patency, while endovascular approaches carry lower stroke risk.
Recommendation 12: Routine monitoring and follow-up
Regular follow-up for PMR, GCA, and TAK must be guided by close monitoring of patient symptoms, clinical findings, and acute phase reactants. While routine imaging is leveraged on an individual basis to monitor structural damage in GCA, it must be used systematically to track both active inflammation and arterial damage in all patients with TAK.
This updated framework achieved a high degree of consensus during voting, with multiple recommendations receiving near-unanimous agreement from the steering committee.
“All of these recommendations have a really high level of agreement, and this is quite unusual in the task forces that I’ve had the privilege of being on,” Professor Mukhtyar said.
“I commend these recommendations to you and urge you to use these in your daily practice.”
The EULAR 2026 Congress was held in London from 3-6 June.
