2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis

OBJECTIVES: This study aimed to update the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of polymyalgia rheumatica (PMR), giant cell arteritis (GCA), and Takayasu arteritis (TAK). METHODS: Following EULAR standard operating procedures, systematic literature reviews identified data published since the previous versions for PMR (2015) and for GCA/TAK (2018). An international task force discussed the evidence, and following a structured voting process, created overarching principles, recommendations, and quality indicators. RESULTS: The task force agreed on 4 overarching principles, 12 recommendations, and 2 quality indicators. All patients with suspected PMR, GCA, or TAK should be referred for specialist assessment and those with suspected GCA within 24 hours. In patients with a strong clinical suspicion of GCA, treatment with glucocorticoids (GCs) should be commenced without delay, while waiting for the results of confirmatory investigations. For most patients with suspected PMR or TAK, treatment with GC can be delayed until the diagnosis is confirmed. For induction of remission, GC should be initiated at a dose of 15 to 25 mg/day prednisone-equivalent for PMR and 40 to 60 mg for GCA or TAK. Guidance on GC tapering is provided. Adjunctive therapy is recommended for selected patients with PMR or GCA using either interleukin (IL)-6 receptor inhibitors for PMR and GCA or upadacitinib for GCA. Methotrexate may be an alternative. GC-sparing agents should be given in combination with GC to all patients with TAK. All overarching principles and recommendations met with high levels of agreement. CONCLUSIONS: Updated guidance on management of PMR and large vessel vasculitis is provided in a single set of practical recommendations and algorithms.