BSR Updates Polymyalgia Rheumatica Treatment Guideline
Key Takeaways
- For adults with polymyalgia rheumatica (PMR), the 2026 British Society for Rheumatology (BSR) guideline supersedes the 2009 BSR/BHPR guidance and recommends starting prednisolone at 12.5 to 15 mg daily.
- A standard glucocorticoid taper is recommended, with a faster taper aiming for discontinuation within 6 months as an option for people at high risk of glucocorticoid toxicity.
- Early referral to consider methotrexate should be discussed with newly diagnosed patients, and IL-6 receptor antagonists can be considered when glucocorticoids cannot be tapered or the response is inadequate.
- Bisphosphonates are recommended for everyone starting glucocorticoids unless contraindicated, and rheumatology referral is advised after a second relapse or 18 months of glucocorticoid therapy.
Glucocorticoids remain the cornerstone of treatment. The guideline recommends starting prednisolone at 12.5 to 15 mg daily, increasing to a maximum of 25 mg daily if needed, and beginning to taper after symptoms have been controlled for 2 to 4 weeks (GRADE 2C). Lower starting doses such as 12.5 mg daily may be used when glucocorticoid toxicity is a concern, for example in patients with diabetes, osteoporosis, or glaucoma. The standard taper reduces the dose by 2.5 mg every 2 to 4 weeks until reaching 10 mg daily, then by 1 mg every 4 to 8 weeks (GRADE 2C).
For people at high risk of glucocorticoid toxicity, a faster taper can be considered once disease activity is controlled, for example reducing by 1 mg every 2 to 3 weeks with the aim of stopping within 6 months (GRADE 2B). This example mirrors the tapering schedule of the PMR-MODE trial, in which 46% of the placebo arm achieved glucocorticoid-free remission at week 52 on a 24-week taper. If PMR relapses, the guideline recommends returning to the last effective dose for 2 to 4 weeks and then considering a slower taper (GRADE 1C). The authors note that no randomized trial has compared different starting doses or planned taper regimens.
For glucocorticoid-sparing treatment, clinicians should discuss with recently diagnosed patients the option of referral to rheumatology to consider adding methotrexate (GRADE 2B), and should consider methotrexate for people who have relapsed or are at higher risk of glucocorticoid toxicity (GRADE 2C). Methotrexate is unlicensed for PMR in the UK but is used off-label. An IL-6 receptor antagonist can be considered for people with an inadequate response to glucocorticoids or who cannot tolerate a taper (GRADE 2B). At the time of writing, sarilumab was licensed for PMR but not commissioned by the UK National Health Service.
Bisphosphonates are recommended for everyone with PMR starting glucocorticoid therapy unless contraindicated, a recommendation graded 1B from external evidence. Because almost all patients meet national thresholds for bone protection, prior FRAX or DEXA risk stratification is not required. A UK target trial emulation cited in the guideline estimated that 109 patients would need bisphosphonate treatment for 12 months to prevent one fragility fracture.
The guideline also sets out monitoring for glucocorticoid toxicity, adrenal insufficiency, and giant cell arteritis. Annual review is suggested as a minimum, with most patients needing review at least every 3 months during the first year and more frequent review during faster tapers. Clinicians should consider discussing a patient with rheumatology after any relapse and should refer after a second relapse. Referral is also recommended for all patients after 18 months or more of glucocorticoid therapy. Ongoing patient education and counseling are emphasized throughout.
These treatment options are guideline recommendations, not patient outcomes measured by the guideline itself. Most treatment recommendations are weak (GRADE 2), reflecting limited trial evidence. Tapering schedules and glucocorticoid-sparing therapy should therefore be understood as considerations for differing clinical circumstances rather than a universal regimen.
Clinician Questions
What glucocorticoid starting dose or faster-taper interval is specified for polymyalgia rheumatica?
The guideline recommends prednisolone 12.5 to 15 mg daily, increasing to no more than 25 mg daily if needed, with tapering beginning after 2 to 4 weeks of symptom control. The standard taper reduces the dose by 2.5 mg every 2 to 4 weeks to 10 mg daily, then by 1 mg every 4 to 8 weeks. For people at high risk of glucocorticoid toxicity, a faster taper can be considered once disease is controlled, for example 1 mg every 2 to 3 weeks, aiming to stop within 6 months. Both taper recommendations are weak (GRADE 2C and 2B), and no randomized trial has directly compared taper regimens.
Do British rheumatology recommendations for polymyalgia rheumatica establish U.S. national treatment policy?
No. The BSR developed these recommendations as British professional-society guidance for UK health professionals, structured around National Health Service care pathways. Some recommendations reflect UK-specific context.