Modern Management of Isolated Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disorder affecting those over 50 years of age. It is clinically heterogenous in both presentation and disease trajectory. Diagnostic complexity is heightened by the absence of a gold standard diagnostic test and the broad spectrum of disease mimics, posing challenges even for experienced rheumatologists. The primary goal of treatment is to restore health-related quality of life by achieving sustained symptom control, suppressing systemic inflammation, and minimising treatment-related toxicity. Despite advances in our understanding of PMR, glucocorticoids (GCs) remain the cornerstone of therapy. However, frequent relapses and prolonged treatment courses in many patients result in high cumulative GC exposure with associated adverse effects, which is of particular concern in this older, typically frailer and more vulnerable patient cohort. The urgent need for effective GC-sparing agents has resulted in pivotal developments over the past decade, notably the SAPHYR trial, which supported the US Food and Drug Administration (FDA) approval of sarilumab as the first biologic therapy for refractory PMR. This represents a major shift in the therapeutic landscape, with several biologic agents now under investigation. These advances, however, highlight gaps in the current management, including the need for rapid access pathways and specialist rheumatologist evaluation in all cases of suspected PMR to facilitate an early and accurate diagnosis, stratified treatment approaches and the accurate detection of a coexisting giant cell arteritis. Furthermore, standardised definitions of relapse and remission, alongside structured monitoring protocols, are lacking. This review explores current diagnostic and treatment strategies for isolated PMR. We also highlight unmet needs in PMR management, and discuss future directions aimed at improving outcomes and redefining the care pathway for PMR.