Glucocorticoid tapering strategies in polymyalgia rheumatica: a systematic literature review

Glucocorticoids (GCs) are the cornerstone of polymyalgia rheumatica (PMR) treatment, but the optimal tapering strategy remains unclear. This systematic review aimed to explore the impact of published GC tapering strategies on remission, flare rates, GC discontinuation, cumulative GC doses and patient-reported outcomes (PROs).

PubMed, EMBASE and Cochrane Library were systematically searched for prospective studies reporting GC tapering protocols and outcomes related to remission, flare, GC discontinuation, GC cumulative dosage and PROs. Two researchers independently extracted data and assessed risk of bias, with discrepancies resolved by a third reviewer. Due to heterogeneity, results were reported descriptively. PROSPERO identification: CRD420250631176.

Eleven studies were included (nine RCTs and two longitudinal cohorts). Duration of tapering protocols varied widely (16-80 weeks), yet one-year remission rates (37-58%) and GC-free rates (33-54%) appeared relatively consistent across studies. Flare rates were generally high (57-100%) and did not appear to differ according to tapering speed. Cumulative GC dosages varied substantially and did not appear to be dependent on tapering duration. Reporting of PROs was limited and heterogeneous.

Despite wide variation in GC tapering duration, clinical outcomes appeared broadly similar across studies, suggesting that faster tapering may not necessarily compromise outcomes. However, the evidence remains limited and therefore does not allow firm conclusions about the optimal tapering approach in PMR. Future research should identify predictors of treatment response and evaluate individualized, treat-to-target tapering strategies. The use of standardized outcome measures, including PROs, will be essential to improve comparability and inform evidence-based future guidelines.