EULAR 2026 Recommendations for the Management of PMR, GCA, and Takayasu Arteritis Save

On the final day of EULAR 2026, Mukhtyar et al (on the on behalf of a large international task force) presented the updated EULAR recommendations for management of polymyalgia rheumatica (PMR), giant cell arteritis (GCA), and Takayasu arteritis (TAK). There were 5 overarching principles and 12 recommendations.

Overarching Principles

• Management decisions should be made collaboratively between THE clinician and patient, weighing efficacy, safety, and costs.
• Diagnosis of PMR, GCA, and TAK rests on clinical signs and symptoms, with imaging or biopsy confirmation required for suspected GCA and TAK.
• Classification criteria should not substitute for clinical diagnosis.
• Patients require access to disease education including warning symptoms and treatment complications.
• Those with LVV should be screened for cardiovascular comorbidities, with prophylactic and lifestyle interventions employed to mitigate risk.

Recommendations by Disorder 

Polymyalgia Rheumatica (PMR)

• All patients with suspected PMR should be referred to a specialist with appropriate expertise. PMR is frequently under-investigated and over-diagnosed, and vascular involvement should be considered.
• Glucocorticoid (GC) treatment can be delayed until diagnosis is confirmed — a trial of GC is not a diagnostic test.
• For new-onset PMR, oral GC at 15–25 mg/day should be tapered to 10 mg/day within 1–2 months, with the aim of stopping within one year.
• In relapsing PMR, GC should be restarted or escalated to at least the last effective dose, followed by individualized tapering. The GC regimen should always aim for the minimum effective dose.
• Relapsing PMR: Relapse diagnosis is based on clinical signs, symptoms, and laboratory markers, supported by imaging where needed.
• For steroid-sparing therapy, tocilizumab may be considered in selected new-onset PMR patients.
  • In relapsing or refractory PMR, sarilumab is preferred, with tocilizumab as an alternative.
  • Methotrexate may be used instead of IL-6 inhibitors in either setting. (Editors note: this is because IL-6 inhibitors are not universally available and there is some, but inconclusive data, on the efficacy of MTX in PMR)
• Refractory PMR should trigger diagnostic re-evaluation — PMR mimics include myositis, inflammatory arthritis, paraneoplastic presentations, myeloma, and other disorders.
• Regular follow-up should be based on symptoms, clinical findings, and acute phase markers.

Giant Cell Arteritis (GCA)

• Suspected cranial GCA requires urgent specialist referral within 24 hours. GCA is a medical emergency — GC should be commenced immediately without waiting for confirmatory investigations, using multimodal diagnostics including imaging and histology in parallel.
• For new-onset GCA, oral GC at 40–60 mg/day should be tapered to 15–20 mg/day within 2–3 months, aiming to stop GC within 12–18 months.
• Major relapse should be treated as new-onset disease with GC reinstitution or dose escalation. Minor relapses require escalation to at least the last effective dose with individualized subsequent tapering.
• Steroid-sparing therapy with tocilizumab or upadacitinib should be considered in GCA, particularly in refractory or relapsing disease or in patients at increased risk of GC-related adverse effects. (Safety considerations for both biologic agents must inform treatment decisions.)
  • Methotrexate remains an alternative.
• Relapse diagnosis relies on clinical assessment and laboratory markers supported by imaging where needed. Notably, up to 20% of GCA relapses present with a new symptom, relapses may occur in a different arterial territory, and GCA and PMR may relapse interchangeably. Imaging should be used selectively to assess for damage on an individual basis.
• Refractory GCA warrants diagnostic re-evaluation and specialist center referral.
• For elective endovascular interventions or reconstructive surgery, procedures should be performed during phases of stable remission. Arterial vessel dissection or critical vascular ischemia requires urgent vascular team referral. Open interventions carry higher primary patency rates; endovascular approaches carry lower stroke risk.

Takayasu Arteritis (TAK)

• Suspected TAK should be referred to a specialist with appropriate expertise.
• Diagnosis is based on clinical signs and symptoms confirmed by imaging or biopsy.
• GC treatment can be delayed until diagnosis is confirmed.
• For newly diagnosed active TAK, GC at 40–60 mg/day should be tapered to 15–20 mg/day within 2–3 months, with a goal of stopping GC within 12–18 months.
• Major relapses are managed as new-onset disease; minor relapses require escalation to at least the last effective dose with individualized tapering.
• Non-biologic DMARDs should be given to all patients with TAK.
• For relapsing or refractory disease despite conventional DMARD therapy, tocilizumab or TNF inhibitors should be considered.
• Relapse diagnosis in TAK is substantially based on imaging, in conjunction with clinical and laboratory assessment — distinguishing it from PMR and GCA where imaging plays a more supportive role.
• Imaging should be used routinely to assess both disease activity and damage in all TAK patients.
• Refractory TAK requires diagnostic re-evaluation, with differentials including Buerger's disease and fibromuscular dysplasia.
• Elective vascular interventions should be performed only during stable remission, with urgent vascular referral for dissection or critical ischemia. Arterial vessel dissection or critical vascular ischemia requires urgent vascular team referral. Open interventions carry higher primary patency rates; endovascular approaches carry lower stroke risk.
• Regular monitoring should incorporate symptoms, clinical findings, acute phase markers, and imaging throughout the disease course.

These EULAR 2026 recommendations formalize a stratified, treat-to-target approach across PMR, GCA, and TAK, with notable additions including upadacitinib as a GCA adjunctive therapy and sarilumab as the preferred IL-6 inhibitor for relapsing PMR — reflecting the maturation of the evidence base in this rapidly evolving field.