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Polymyalgia rheumatica: 2025 EULAR and 2026 British guidelines, plus new methotrexate, IL-6 receptor antagonist and ultrasound data

In a small 2026 placebo-controlled trial of recently diagnosed PMR (64 randomized, 58 analyzed), 80% on methotrexate versus 46% on placebo reached glucocorticoid-free remission at 52 weeks; a 2026 British guideline includes consideration of early methotrexate.

4 min read · 7 references · References retrieved 18 October 2026
Educational content for healthcare professionals. Not medical advice. AI-generated and not authored or reviewed by a licensed physician. Verify against current guidelines and product labeling before any clinical decision.

The 2015 EULAR/ACR recommendations for polymyalgia rheumatica (PMR) covered initial glucocorticoid doses, tapering and disease-modifying drugs [1]. EULAR's 2025 recommendations for PMR and primary large vessel vasculitis were published online in July 2026 [2]. The 2026 British Society for Rheumatology guideline is the other recent update [3]. Neither is a US guideline [2] [3].

What do the 2025 EULAR and 2026 British guidelines say?

The 2025 EULAR update covers PMR together with giant cell arteritis and Takayasu arteritis, and its task force agreed on 4 overarching principles, 12 recommendations and 2 quality indicators [2]. For most patients with suspected PMR, EULAR states that glucocorticoids can be delayed until the diagnosis is confirmed, whereas treatment should start without delay when giant cell arteritis is strongly suspected [2]. EULAR sets an induction range of 15 to 25 mg/day prednisone-equivalent for PMR [2]. EULAR 2025 recommends adjunctive interleukin-6 (IL-6) receptor antagonists for selected patients with PMR and states that methotrexate may be an alternative [2].

The 2026 British Society for Rheumatology (BSR) guideline was developed using the GRADE and AGREE II frameworks and supersedes the 2009 BSR/BHPR guideline [3]. The BSR 2026 recommendations include [3]:

  • When to discuss or refer people with PMR to rheumatology [3].
  • Glucocorticoid initiation and tapering, with options for a faster taper [3].
  • Consideration of methotrexate early in the disease course [3].
  • IL-6 receptor antagonists for people who cannot taper glucocorticoids or whose response is inadequate [3].
  • Bone protection for all people with PMR [3].

What does the new trial and meta-analysis evidence show?

In a 2026 double-blind placebo-controlled trial of recently diagnosed PMR with under 8 weeks of glucocorticoid use (64 randomized, 58 analyzed), glucocorticoid-free remission at 52 weeks occurred in 80% of patients given methotrexate 25 mg/week and 46% given placebo (risk difference 34 percentage points; 1-sided 95% CI 14 percentage points), alongside a 24-week glucocorticoid-tapering protocol [4]. The 2026 trial authors note that earlier randomized trials had tested 7.5 to 10 mg/week and reported conflicting results [4].

A 2025 meta-analysis of 3 randomized trials (n=188) found glucocorticoid-free remission at week 24 was more frequent with the IL-6 receptor antagonist tocilizumab than with placebo (risk ratio 2.64; 95% CI 1.38 to 5.06) [5]. The same 2025 meta-analysis found no significant difference in infections (risk ratio 1.19; 95% CI 0.92 to 1.52) [5]. A 2026 meta-analysis of 4 randomized trials (n=317) reported lower short-term relapse odds with tocilizumab than with placebo (odds ratio 0.22; 95% CI 0.12 to 0.41) [6].

How accurate is ultrasound in suspected PMR?

A 2026 multicenter diagnostic study enrolled consecutive glucocorticoid-naive patients with suspected PMR in a retrospective cohort (n=92) and a prospective cohort (n=93) [7]. The 2026 study found no single ultrasound finding was pathognomonic for PMR [7]. In the 2026 study, at least one inflammatory lesion had a sensitivity of 93% (95% CI 83 to 98) in the retrospective cohort (10 sites scanned) and 92% (95% CI 83 to 98) in the prospective cohort (6 sites scanned) [7]. In the same study, at least one inflammatory lesion in both the shoulder and hip girdles had a specificity of 85% (95% CI 69 to 95) in the retrospective cohort and 93% (95% CI 76 to 99) in the prospective cohort [7].

Where is the evidence uncertain?

The trials pooled in the 2025 meta-analysis enrolled different populations: early PMR, glucocorticoid-dependent PMR and PMR with giant cell arteritis [5]. Both the 2025 and 2026 meta-analyses studied tocilizumab alone, so neither estimates the class; they measure different outcomes (remission at week 24 versus short-term relapse) and pool different trial sets, so their ratios are not comparable [5] [6]. The 2026 methotrexate trial authors described their study as small and called for research on the timing of methotrexate initiation [4]. In the 2026 ultrasound study, discrimination was weaker against other inflammatory rheumatic diseases than against non-inflammatory conditions [7].

At the point of care: what to check

  • Suspected giant cell arteritis: whether clinical suspicion is strong, the situation in which EULAR 2025 states that treatment should not wait for confirmatory investigations [2].
  • Glucocorticoid taper failure or inadequate response: the situation the BSR 2026 guideline links to IL-6 receptor antagonists [3].
  • Fracture risk and bone protection status: BSR 2026 includes bone protection for all people with PMR [3].
  • Time since diagnosis and glucocorticoid exposure: the 2026 methotrexate trial enrolled recently diagnosed patients with under 8 weeks of glucocorticoid use [4].
  • Ultrasound: any inflammatory lesion, and lesions in both the shoulder and hip girdles, the findings with the highest sensitivity and the highest specificity in the 2026 study [7].

References

  1. Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015;74(10):1799-1807 doi:10.1136/annrheumdis-2015-207492. https://pubmed.ncbi.nlm.nih.gov/26359488/ — accessed 18 October 2026.
  2. Mukhtyar CB, Nikiphorou E, Bartoletti A, et al. 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis. Ann Rheum Dis. 2026 Jul 21 (online ahead of print) doi:10.1016/j.ard.2026.06.009. https://pubmed.ncbi.nlm.nih.gov/42481270/ — accessed 18 October 2026.
  3. Toyoda T, Bhide S, Boland C, et al. The 2026 British Society for Rheumatology guideline for the treatment of polymyalgia rheumatica. Rheumatology (Oxford). 2026;65(10):keag502 doi:10.1093/rheumatology/keag502. https://pubmed.ncbi.nlm.nih.gov/42869454/ — accessed 18 October 2026.
  4. Bolhuis TE, et al. Results of a 1-year randomised double-blind placebo-controlled trial with methotrexate 25 mg/week in recently diagnosed polymyalgia rheumatica. Ann Rheum Dis. 2026;85(4):761-770 doi:10.1016/j.ard.2025.11.025. https://pubmed.ncbi.nlm.nih.gov/41423373/ — accessed 18 October 2026.
  5. Baral B, et al. Efficacy and Safety of Tocilizumab in Polymyalgia Rheumatica: A Systematic Review and Meta-analysis of Randomized Controlled Trials. ARP Rheumatol. 2025;4(2):145-153 doi:10.63032/HYAU2255. https://pubmed.ncbi.nlm.nih.gov/40629823/ — accessed 18 October 2026.
  6. Bungish MK, Mohsan M, Farooq H, et al. Steroid-sparing strategies in polymyalgia rheumatica: a systematic review and meta-analysis of tocilizumab with practical guidance for tapering. BMC Rheumatol. 2026;10(1):48 doi:10.1186/s41927-026-00625-z. https://pubmed.ncbi.nlm.nih.gov/42035168/ — accessed 18 October 2026.
  7. Våben CS, Nielsen AW, Sandovici M, et al. Diagnostic accuracy of musculoskeletal ultrasound in suspected polymyalgia rheumatica: a multicentre, cohort study. Lancet Rheumatol. 2026;8(10):e776-e787 doi:10.1016/S2665-9913(26)00187-6. https://pubmed.ncbi.nlm.nih.gov/42767765/ — accessed 18 October 2026.

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