Summary

First joint EULAR/ACR recommendations for management of polymyalgia rheumatica, developed using GRADE methodology. Provides 8 overarching principles and 9 specific recommendations covering baseline workup, glucocorticoid dosing and tapering, IM methylprednisolone alternative, early methotrexate use, exclusion of TNF inhibitors, and exercise. Emphasizes individualized minimum-effective GC dosing and shared decision-making rather than fixed schedules.

Key Recommendations

Use glucocorticoids rather than NSAIDs as first-line therapy for PMR; reserve NSAIDs/analgesics for short-term use for non-PMR pain.
Start initial oral prednisone at the minimum effective dose within 12.5–25 mg/day; favor higher end for high relapse risk, lower end for comorbidities/GC-adverse-event risk.
Avoid initial prednisone doses ≤7.5 mg/day (conditionally) and never exceed 30 mg/day (strong).
Taper to 10 mg/day prednisone equivalent within 4–8 weeks, then reduce by 1 mg every 4 weeks (or equivalent alternate-day regimens) once remission achieved.
For relapse, increase prednisone to pre-relapse dose then taper back over 4–8 weeks to the dose at which relapse occurred.
Consider IM methylprednisolone (120 mg every 3 weeks) as alternative to oral GCs, particularly when lower cumulative GC exposure is desirable.
Use single rather than divided daily oral GC doses, except for prominent night pain at low-dose tapering (<5 mg/day).
Consider early adjunctive methotrexate (7.5–10 mg/week PO) in patients at high risk of relapse, prolonged therapy, GC adverse events, or with relapsing/refractory disease.
Strongly recommend against TNF-α inhibitors for PMR treatment.
Strongly recommend against Chinese herbal preparations Yanghe and Biqi capsules.
Prescribe an individualized exercise program to preserve muscle mass/function and reduce falls in older or frail patients on long-term GCs.
Refer to specialist for atypical features (peripheral arthritis, systemic symptoms, low inflammatory markers, age <60), GC adverse events, refractory disease, or prolonged therapy.

Thresholds & Doses

Initial prednisone: 12.5–25 mg/day (minimum effective dose).
Avoid initial prednisone ≤7.5 mg/day; do not exceed 30 mg/day.
Initial taper target: 10 mg/day prednisone equivalent within 4–8 weeks.
Maintenance taper after remission: reduce prednisone by 1 mg every 4 weeks (or 1.25 mg decrements such as 10/7.5 mg alternate days) until discontinuation.
Relapse taper: re-taper to pre-relapse dose within 4–8 weeks.
IM methylprednisolone starting dose: 120 mg every 3 weeks (through week 9), then 100 mg at week 12, monthly with 20 mg reductions every 12 weeks to week 48, then 20 mg every 16 weeks until discontinuation.
Methotrexate dose used in trials: 7.5–10 mg/week orally.
Follow-up: every 4–8 weeks in year 1, every 8–12 weeks in year 2, and as indicated for relapse/tapering.
ESR >40 mm/hour identified as risk factor for relapse/prolonged therapy.
Atypical-presentation referral threshold: age <60 years.
Initial lack of response (insufficient improvement within 2 weeks): increase oral prednisone up to 25 mg/day.

Citations

Box 1 (Overarching principles 1–8) — baseline labs, comorbidity assessment, monitoring intervals, and specialist referral criteria.
Specific Recommendation 1 — GCs preferred over NSAIDs.
Specific Recommendation 3 — initial prednisone 12.5–25 mg/day range with dose caps.
Specific Recommendation 4 (A–C) — initial, relapse, and maintenance tapering schedules.
Specific Recommendation 5 — IM methylprednisolone 120 mg every 3 weeks regimen.
Specific Recommendation 6 — single daily GC dosing.
Specific Recommendation 7 — early methotrexate 7.5–10 mg/week adjunct.
Specific Recommendations 8 and 10 — against TNF inhibitors and against Yanghe/Biqi herbal preparations.
Figure 1 algorithm — overall PMR management flow including assessment, initiation, tapering, and relapse pathways.