Suspected GCA or PMR
Adults aged 50 or over. Under 50: consider other diagnoses (for example Takayasu arteritis). Suspected GCA is an emergency.
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RheumatologyManagement
Giant Cell Arteritis & PMR Management (EULAR 2025)
Giant Cell Arteritis & PMR Management (EULAR 2025): Suspected GCA or PMR → Assess every patient for GCA and PMR features → Strong clinical suspicion of ...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Assess every patient for GCA and PMR features
GCA and PMR often coexist or follow each other. Ask about GCA symptoms even when PMR seems likely.
- GCA: new headache, scalp tenderness, jaw claudication, visual symptoms, abnormal temporal artery, arm claudication
- PMR: bilateral shoulder and/or hip girdle pain with morning stiffness
- Check ESR, CRP and FBC now; do not wait for results to treat suspected GCA
- Consider mimics: infection, cancer, RA and other inflammatory disease
03Decision Strong clinical suspicion of GCA?
Yes if cranial symptoms (new headache, scalp tenderness, jaw claudication, visual disturbance) or arm claudication. No: go to the PMR step, which also checks for large-vessel GCA.
- If Yes
- GCA suspected
04Warning Visual loss or other ischaemic symptoms: GCA emergency
Vision loss, amaurosis fugax, diplopia, stroke or TIA symptoms: give glucocorticoid now; same-day ophthalmology and specialist review.
- Give glucocorticoid now; do not wait for blood tests, imaging or biopsy
- Adult: IV methylprednisolone 500 mg-1 g once daily for 3 days, or prednisolone 60 mg orally now if IV would cause delay
- Same-day ophthalmology and rheumatology review; admit if needed
05Action Suspected GCA: start prednisolone 40-60 mg daily today
Adult, oral, once daily. Do not delay for imaging or biopsy. Refer to a specialist within 24 hours.
- Prednisolone 40-60 mg orally once daily; keep this dose until symptoms resolve
- Diabetes: do not withhold glucocorticoid; monitor glucose closely and adjust diabetes treatment
- Aspirin: not routine; use only for another indication (for example coronary, carotid or vertebral artery disease); add a PPI if used
- Start the harm-prevention steps below at the same time
06Action GCA: confirm with imaging or biopsy soon after starting treatment
GCA diagnosis needs imaging or biopsy. Test early: treatment lowers the yield.
- Ultrasound of temporal and axillary arteries is first line (halo sign)
- Alternatives: FDG-PET or MRI of cranial and extracranial arteries
- Temporal artery biopsy (specimen over 1 cm) if imaging is not available or inconclusive; aim within 2 weeks of starting glucocorticoid
- Negative test but high suspicion: do not stop glucocorticoid without specialist review
- Consider baseline imaging of the aorta and its branches (MRA, CTA, PET or ultrasound) for large-vessel involvement
07Warning GCA: prevent glucocorticoid harm from the start
Start these with glucocorticoid. They must not delay glucocorticoid.
- Bone: calcium, vitamin D and DXA; most need an osteoporosis drug (30 mg/day or more for over 30 days = very high fracture risk)
- Screen and treat glucose (HbA1c), BP, lipids and weight gain
- Infection: screen hepatitis B and latent TB, and Strongyloides if from an endemic area; consider PJP prophylaxis while above 15-30 mg/day for over 2-4 weeks
08Decision GCA: add a glucocorticoid-sparing drug?
Consider in all GCA. Yes especially if relapsing or refractory disease, or high risk of glucocorticoid harm (for example diabetes, osteoporosis, CV disease).
- If Yes
- Add GC-sparing drug
09Warning Before tocilizumab or upadacitinib: screen and exclude active infection
Tocilizumab suppresses CRP and fever, so infection can be missed.
- Do not start with active severe infection; stop it during a serious infection
- Screen latent TB (IGRA), hepatitis B and C first; hepatitis B core antibody positive or prior hepatitis C: not recommended
- Past diverticulitis or intestinal ulceration: perforation risk, use with caution; no live vaccines during treatment
10Action GCA: tocilizumab 162 mg SC weekly with a glucocorticoid taper
Adult. TGA-registered for GCA (subcutaneous only). Specialist-initiated.
- Tocilizumab 162 mg SC once weekly; every 2 weeks only if clinically needed (for example low neutrophils or raised ALT)
- Do not start tocilizumab if neutrophils below 2 x10^9/L or ALT/AST above 1.5 x ULN; caution if platelets below 100 x10^9/L
- Usually 12 months; longer if high relapse risk; taper rather than stop abruptly
- Monitor ALT/AST every 4-8 weeks for 6 months then every 12 weeks; neutrophils, platelets and lipids 4-8 weeks after start
- Alternative: upadacitinib 15 mg orally daily (not TGA-registered for GCA); use only if no suitable alternative in age 65 or over, smokers, CV disease, VTE risk or cancer
- Alternative: methotrexate 15-20 mg SC once a week only (never daily); check FBC, LFTs and creatinine first; avoid in severe renal impairment; monitor FBC if on co-trimoxazole
- New abdominal pain: assess promptly for bowel perforation
11Action GCA taper: 15-20 mg/day by 2-3 months, stop by 12-18 months
Individualise. With tocilizumab or upadacitinib the taper can be shorter.
- Once symptoms resolve, taper to 15-20 mg/day within 2-3 months
- Aim to stop glucocorticoid within 12-18 months; trials with tocilizumab or upadacitinib used a 26-week taper
- Review every 1-4 weeks until remission, then every 3-6 months
- On tocilizumab, CRP can stay normal during relapse: judge by symptoms and imaging
- Taper slowly below 5 mg/day; watch for adrenal insufficiency
12Decision In remission?
Remission: no symptoms and no systemic inflammation (normal ESR/CRP).
- If Yes
- Remission
13Outcome In remission: minimum effective dose, aim to stop
Aim for glucocorticoid-free remission. Review every 3-6 months. GCA: watch for aortic aneurysm; imaging per specialist.
If No- Active or relapse
14Action Not in remission or relapse: confirm, then escalate
Confirm with symptoms, signs, ESR/CRP, and imaging if needed. Consider mimics.
- GCA major relapse (ischaemic features, such as visual symptoms or jaw claudication): glucocorticoid as for new GCA, urgently
- GCA minor relapse: raise glucocorticoid to at least the last effective dose; add tocilizumab (after TB and hepatitis screening), upadacitinib or methotrexate
- PMR relapse: restart or raise glucocorticoid to at least the last effective dose, then taper; consider methotrexate
- Arterial dissection or critical limb ischaemia: urgent vascular team referral
15Decision Still active despite escalation?
Refractory or frequently relapsing disease.
- If Yes
- Refractory
16Outcome Refractory: re-evaluate the diagnosis, specialist centre
Look again for infection, cancer or another vasculitis. Refer to a specialist vasculitis centre.
If No- Reassess
- Path rejoins step 12Shared downstream outcome
If No- Glucocorticoid alone
- Path rejoins step 11Shared downstream outcome
If No- Probable PMR
17Action No cranial GCA features: probable PMR, confirm before glucocorticoid
PMR is not an emergency. Refer for specialist assessment. Avoid a diagnostic trial of glucocorticoid.
- Typical: age 50 or over, bilateral shoulder and/or hip girdle pain, morning stiffness, raised ESR/CRP
- Fever, weight loss, very high ESR/CRP, arterial bruits or unequal arm BP: possible large-vessel GCA; urgent specialist review and vascular imaging
- Tests: FBC, ESR, CRP, creatinine, LFTs, glucose, calcium, ALP, urinalysis, RF and/or anti-CCP; consider TSH, CK, protein electrophoresis
- Exclude mimics: infection, cancer, RA and other inflammatory arthritis, myopathy, hypothyroidism
- Ultrasound of shoulders and hips can support an atypical case
18Warning Before PMR glucocorticoid: exclude GCA and mimics
Check these before and during treatment.
- Headache, jaw claudication or visual symptoms at any time: treat as GCA now
- Exclude infection and cancer first; Strongyloides serology if from an endemic area
- Plan bone protection (calcium, vitamin D, DXA), glucose and BP checks from the start
19Action PMR: prednisolone 15-25 mg/day orally
Adult, once daily. Use the lowest effective dose in the range.
- Lower dose in the range if diabetes, osteoporosis or glaucoma; higher if high relapse risk
- Expect a clear response; if symptoms persist, reconsider the diagnosis
- High risk of glucocorticoid harm or relapse: specialist may add methotrexate
- IL-6 receptor inhibitors (sarilumab, tocilizumab) are EULAR options but are not TGA-registered for PMR
20Action PMR taper: 10 mg/day by 1-2 months, aim to stop within 1 year
Individualise the taper to the patient and the disease.
- Taper to 10 mg/day within 1-2 months once symptoms are controlled
- Then taper slowly while in remission, for example by 1 mg every 4 weeks
- Review every 1-4 weeks until remission, then every 3-6 months
- Taper slowly below 5 mg/day; watch for adrenal insufficiency
- Path rejoins step 12Shared downstream outcome
Guideline Source
2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Specialist-led conditions: refer suspected GCA within 24 hours (same day with visual symptoms); PMR needs specialist confirmation before glucocorticoid where possible
- Australia: tocilizumab is TGA-registered for GCA only; upadacitinib (GCA) and IL-6 receptor inhibitors (PMR) are not TGA-registered for these uses
- Adults aged 50 or over only; children and Takayasu arteritis are not covered
- Large-vessel GCA complications (aneurysm, dissection, stenosis) need vascular specialist input
- Drug doses are adult doses; check renal and hepatic function before methotrexate or upadacitinib
Contraindicated Populations
pediatricadults under 50 years (consider other diagnoses)
Applicable Regions
EUUSAU
AU: Tocilizumab SC 162 mg is TGA-registered for adult GCA. Upadacitinib has no GCA indication in the Australian PI, and no sarilumab PI is listed with the TGA. Screen for Strongyloides before high-dose glucocorticoid in people from endemic areas, including many remote Aboriginal and Torres Strait Islander communities.
EU: 2025 EULAR recommendations (PMR, GCA, Takayasu) are the primary guidance; they replace EULAR/ACR 2015 (PMR) and EULAR 2018 (large vessel vasculitis).
US: 2021 ACR/Vasculitis Foundation GCA guideline also applies. Tocilizumab and upadacitinib are FDA-approved for GCA; sarilumab is FDA-approved for PMR.
Version 2Next review: 2027-09-28
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Related Resources
Frequently Asked Questions
What is the Giant Cell Arteritis & PMR Management (EULAR 2025)?
The Giant Cell Arteritis & PMR Management (EULAR 2025) is a management clinical algorithm for Rheumatology. It provides a structured decision tree to guide clinical decision-making, based on 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis.
What guideline is the Giant Cell Arteritis & PMR Management (EULAR 2025) based on?
This algorithm is based on 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis (DOI: 10.1016/j.ard.2026.06.009).
What are the limitations of the Giant Cell Arteritis & PMR Management (EULAR 2025)?
Known limitations include: Specialist-led conditions: refer suspected GCA within 24 hours (same day with visual symptoms); PMR needs specialist confirmation before glucocorticoid where possible; Australia: tocilizumab is TGA-registered for GCA only; upadacitinib (GCA) and IL-6 receptor inhibitors (PMR) are not TGA-registered for these uses; Adults aged 50 or over only; children and Takayasu arteritis are not covered; Large-vessel GCA complications (aneurysm, dissection, stenosis) need vascular specialist input; Drug doses are adult doses; check renal and hepatic function before methotrexate or upadacitinib. Individual patient factors may require deviation from these recommendations.
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