New pathways for polymyalgia rheumatica care

Updated guidance for polymyalgia rheumatica (PMR) care

Article kindly written by Lindsay Turner, Clinical Guidelines Programme Manager, BSR

The British Society for Rheumatology (BSR) has published an updated guideline for the treatment of polymyalgia rheumatica (PMR). The guideline is endorsed by the Royal College of General Practitioners (RCGP) and the Primary Care Rheumatology and Musculoskeletal Medicine Society (PCRMM). It brings together the latest evidence and expert consensus to support safer, more consistent care for people living with this common inflammatory rheumatic condition.

PMR usually affects people over 50. It commonly causes pain and stiffness around both shoulders, and often the neck and hips too. Symptoms are typically worse in the morning and can make everyday tasks difficult, from getting dressed and brushing hair to rising from a chair or climbing stairs. Fatigue is also common. For many people, PMR has a significant impact on quality of life, so timely treatment and appropriate follow-up matter.

The guideline is especially useful for primary and community care teams, because most people with PMR in the UK are diagnosed and managed in primary care. It recognises the role of GPs, nurses, pharmacists, physiotherapists and other allied health professionals, while giving clearer advice on when specialist rheumatology input may be needed.

Key messages for practice

• Start newly diagnosed PMR with 12.5–15 mg prednisolone daily, adjusting if needed for symptom control.
• Prescribe bisphosphonate bone protection when glucocorticoid treatment begins, unless contraindicated.
• Provide clear information on steroid safety, sick day rules, relapse and symptoms of giant cell arteritis that need urgent attention.
• Consider discussing the patient with rheumatology after any relapse and refer after a second relapse.
• Seek specialist advice where there is diagnostic uncertainty, atypical features, treatment toxicity or difficulty tapering glucocorticoids.

Personalising treatment and reducing steroid-related risks

Glucocorticoids remain the main treatment for PMR. For newly diagnosed PMR, the guideline recommends 12.5–15 mg prednisolone daily, increasing to a maximum of 25 mg if needed for symptom control. Once symptoms have been controlled for 2–4 weeks, the dose should be tapered. A typical taper is by 2.5 mg every 2–4 weeks until 10 mg daily, then by 1 mg every 4–8 weeks. For some people at higher risk of steroid-related harm, a faster taper may be appropriate, provided there is careful monitoring and shared decision-making.

One of the most helpful messages for day-to-day practice is that PMR treatment should not be seen simply as “start steroids and slowly taper”. The guideline places much more emphasis on individualised care, continuity, patient education and active monitoring. Follow-up needs to consider whether symptoms are controlled, whether relapse or giant cell arteritis (GCA) symptoms are emerging, and whether treatment itself is causing harm.

Bone protection is one of the clearest practical recommendations. The guideline recommends prescribing bisphosphonates for people with PMR starting glucocorticoid therapy, unless contraindicated. This is intended to reduce fracture risk early, rather than waiting until osteoporosis has developed. Calcium intake and vitamin D status should also be reviewed.

When to seek specialist rheumatology advice

The update also gives useful prompts for involving rheumatology. People with atypical features, diagnostic uncertainty, clinical complexity or a poor response to treatment should be discussed with or referred to specialist care. The guideline suggests considering discussion with rheumatology after any relapse, using routes such as NHS Advice and Guidance where available, and referring after a second relapse. Specialist input should also be considered when steroid toxicity, prolonged treatment or difficulty tapering becomes a concern.

The guideline also brings steroid-sparing treatments into sharper focus. It recommends discussing referral to rheumatology for people recently diagnosed with PMR to consider methotrexate alongside glucocorticoids, with the aim of improving symptoms and helping people stop steroids sooner. Methotrexate may also be considered for people who relapse or who are at higher risk of steroid-related toxicity. The guideline also reviews evidence for interleukin-6 receptor antagonists in people who have an inadequate response to glucocorticoids or cannot tolerate tapering, although availability within the UK NHS remains limited.

For primary care teams, the guideline can help shape more structured PMR reviews. It highlights the importance of clear written or digital information, steroid counselling including sick day rules and Steroid Emergency Cards, a plan for what to do if symptoms relapse, and advice on GCA symptoms that need urgent attention. It also encourages access to trusted resources such as PMRGCAuk, Arthritis UK and NHS information. Physical activity and exercise are included as part of holistic care, particularly for muscle strength, balance, falls risk and general wellbeing.

This is a welcome publication because it reflects the realities of PMR care in the UK. Primary care will continue to play a leading role, but the guideline supports a more proactive approach: treating symptoms effectively, reducing avoidable steroid-related harm and identifying earlier when someone may benefit from rheumatology advice or glucocorticoid-sparing treatment.

BSR encourages healthcare professionals involved in PMR care to read the updated guideline and consider how it could support local practice. This might include reviewing steroid tapering templates, medication review processes, referral pathways and the information given to patients at diagnosis. Small changes to these everyday touchpoints could help improve safety and give people with PMR clearer expectations about their treatment.

BSR will also be hosting a free webinar in January for everyone involved in PMR care, offering an opportunity to explore the updated guideline and its implementation in more detail. Booking will be available via the BSR website.