Abstract
Objectives
To study the implementation of the 2015 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) management recommendations for polymyalgia rheumatica (PMR) among rheumatologists and general practitioners (GPs).
Methods
An online survey (Survey Monkey) comprising 28 questions was distributed among members of the EULAR Study Group on PMR and giant cell arteritis (n=375). Each member was asked to invite at least one GP (snowball principle) with experience in PMR to participate. Statistical analysis included descriptive statistics; differences were tested using Fisher’s exact test.
Results
There were 308 respondents from 37 countries including data from 211 rheumatologists and 73 GPs. Adherence to the 2015 EULAR/ACR recommendations was higher among rheumatologists (83%) than GPs (35%). Rheumatologists (96%) prescribed glucocorticoids more frequently at dosages within the recommended range than GPs (84%). Concerning tapering, a similar proportion of rheumatologists (83%) and GPs (72%) reached the suggested 10 mg prednisone equivalent after 4–8 weeks. Almost all rheumatologists used methotrexate as a glucocorticoid-sparing agent (95%) as compared with only 26% of GPs. Similarly, 70% of rheumatologists, but only 2% of GPs, had experience with interleukin-6 receptor inhibitors for PMR. For follow-up, more rheumatologists preferred scheduled (as opposed to on demand) visits than GPs (99% vs 82%), while more GPs than rheumatologists (47% vs 31%) planned a short follow-up interval (4–8 weeks) in the first year of disease.
Conclusion
Implementation of the EULAR/ACR recommendation for the management of PMR remains incomplete, particularly among GPs. Future updates should incorporate projects to foster diffusion and implementation of the recommendations among all professionals managing this disease.
Keywords: Polymyalgia Rheumatica, Glucocorticoids, Treatment, Methotrexate
WHAT IS ALREADY KNOWN ON THIS TOPIC.
WHAT THIS STUDY ADDS
While most rheumatologists participating in this study adhere to the EULAR/ACR recommendations, only a minority of general practitioners (GPs) were aware of it.
Rheumatologists prescribed initial glucocorticoid (GC) doses more frequently within the recommended dose range than GPs.
GC-sparing agents, particularly methotrexate and interleukin-6 receptor inhibitors, are commonly used by rheumatologists but only occasionally by GPs.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The next update of the PMR management recommendations should develop a specific plan for implementation for both specialty and non-specialty providers.
Better definition of care pathways is required to secure timely access to emerging GC-sparing agents available in patients with PMR.
Introduction
Polymyalgia rheumatica (PMR) is one of the most frequent inflammatory rheumatic diseases in older adults.1 While international recommendations suggest that individuals with suspected or recently diagnosed PMR should be considered for specialist evaluation,2 the majority of PMR patients are still diagnosed and managed in primary care.3 4 Management recommendations endorsed by the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) were developed in 2015 addressing patient stratification and care pathways, glucocorticoid (GC) treatment including initial GC dose and suggested tapering regimen, and the use of GC-sparing agents, particularly methotrexate (MTX).5 Although the implementation of management recommendations has recently been identified as a priority by EULAR task forces,6 it is still unknown to what extent the EULAR/ACR PMR recommendations are followed in clinical practice.
The objective of the present study was to gather information on the implementation of the 2015 EULAR/ACR management recommendations for PMR among rheumatologists and general practitioners (GPs).
Methods
An English-language questionnaire was developed by the cochairs and members of the EULAR giant cell arteritis (GCA)-PMR study group.7 The questionnaire contained 28 questions organised in the following sections: (1) general information (eight questions), (2) GC treatment and tapering (10 questions), (3) GC sparing agents (seven questions) and (4) monitoring and personalisation (three questions). Most questions were in the single-choice format, some multiple-choice questions were also included. In the category GC sparing agents, three questions concerned the use of interleukin-6 receptor (IL-6R) blocking therapy, even though these were not addressed by the 2015 EULAR/ACR recommendations.5 These questions were included in view of the recent FDA and EMA approval of sarilumab for the treatment of relapsing and refractory PMR.8 The full questionnaire is available in online supplemental file 2.
The survey was distributed among the members of the study group (n=375). The questionnaire was accompanied by an explanatory letter regarding the purpose of the survey and the request to forward the survey to at least one GP (snowball principle) with experience in PMR management. The answers were collected via an online survey tool (SurveyMonkey) throughout the month of October 2025. The target audience of the survey was rheumatologists and GPs.
Descriptive and summary statistics were applied to the questionnaire responses. Absolute and relative frequencies were calculated and depicted in tabular form. Data are presented as number (numerator) and percentage of all available responses to each question (denumerator) throughout the manuscript. The denumerator may change from question to question given that individual answers could have been skipped, which were excluded from the denominator as indicated, or because of specific subgroup analyses. For questions in the multiple-choice format, the sum of numerators may exceed the corresponding denumerator. All statistical analyses have been conducted using R. Differences between subgroups were tested using Fisher’s exact test (Fisher’s exact test for count data with simulated p value based on 10 000 replicates). None of the p values reported in the manuscript has been adjusted for multiple testing.
Results
Demographics
A total of 308 responses were collected from participants across 37 countries. The highest number of responses were from healthcare professionals based in Italy (n=72, 23%). See online supplemental table 1 for number of responses from all countries. The number of responses per question ranged from 159 to 282. Most respondents were rheumatologists (n=211, 68.5%) or GPs (n=73, 23.7%). Demographic data of all respondents are summarised in table 1.
Table 1. Demographic characteristics of respondents.
| Variable | N (%) |
|---|---|
| Specialty | |
| Rheumatology | 211 (68.5) |
| General medicine (GP) | 73 (23.7) |
| Internal medicine | 16 (5.2) |
| Geriatrics | 2 (0.6) |
| Orthopaedic surgery | 2 (0.6) |
| Rehabilitation | 2 (0.6) |
| Nuclear medicine | 1 (0.3) |
| Radiology | 1 (0.3) |
| Female sex | 150 (48.7) |
| Age | |
| <35 | 49 (15.9) |
| 35–44 | 89 (28.9) |
| 45–54 | 86 (27.9) |
| 55–64 | 58 (18.8) |
| ≥65 | 26 (8.4) |
| Position | |
| Resident/fellow | 45 (14.6) |
| Senior consultant/professor | 87 (28.2) |
| Specialist/consultant | 169 (54.9) |
| Unknown | 7 (2.3) |
| Experience with PMR | |
| <5 years | 48 (15.6) |
| 5–10 years | 77 (25.0) |
| 11–20 years | 95 (30.8) |
| ≥20 years | 88 (28.6) |
GP, general practitioner; PMR, polymyalgia rheumatica.
In the subsequent sections, we report on the results for rheumatologists and GPs as these professionals were the primary target of the survey. In addition, we conducted sensitivity analyses by including data from the 24 respondents from other specialties who treated at least six patients with PMR per year, either within the rheumatologist (if working in secondary/tertiary care) or the GPs group (if in primary care). This resulted in the inclusion of an additional nine responses into the group of rheumatologists and five into the group of GPs. See online supplemental table 2 for details. For all data reported below, there was no difference between the primary and the sensitivity analysis.
Overall, 163/211 (77.3%) rheumatologists reported working in an academic setting and 48/211 (22.7%) in a community-based hospital, private practice or other clinical settings. Twenty-five (11.8%) rheumatologists were fellows and 186 (88.2%) specialists, 128 (60.7%) had more than 10 years of experience with PMR and 83 (39.3%) 10 years or less.
Among GPs, 6/73 (8.2%) were employed in an academic setting; 48/67 (71.6%) responded that they had completed training; and 39/73 (53.4%) had >10 years of experience with PMR.
As expected, the number of regularly followed patients with PMR differed between the professions: 54/73 (74.0%) of GPs reported to see 1–5 patients/year, 13/73 (17.8%) 6–10/year, 6/73 (8.2%) 11–20/year and none >20/year. Among rheumatologists, 81/211 (38.4%) visit up to 20 patients per year, 73/211 (34.6%) 21–50 and 57/211 (27.0%) >50 patients per year.
Adherence to the 2015 EULAR/ACR recommendations for the management of PMR
Most rheumatologists reported being highly familiar with the EULAR/ACR PMR recommendations (161 of 203 responding to this question (79.3%)), whereas only a minority of GPs gave the same answer (5/58 (8.6%), p<0.001) (figure 1A). Consequently, self-reported adherence to the recommendations was higher among rheumatologists than GPs (169/203 (83.3%) vs 20/58 (34.5%) p<0.001) (figure 1B).
Figure 1. Familiarity with (A) and adherence to (B) the 2015 EULAR/ACR management recommendations for polymyalgia rheumatica among general practitioners (GPs) and rheumatologists. Data are shown as pie diagrams with the absolute and relative number of responses for each group. For both panels, answers for general practitioners are displayed on the left side; answers for rheumatologists are displayed on the right side. ACR, American College of Rheumatology; EULAR, European Alliance of Associations for Rheumatology.
Only two rheumatologists (0.9%) and 23 (40.4%) GPs reported that they were not familiar with the recommendations, while the remainder were at least somewhat familiar with this publication (online supplemental table 2).
Initial GC treatment and tapering
Rheumatologists (194/203 (95.6%)) were more likely to prescribe an initial GC dose within the range specified by the EULAR/ACR recommendations (12.5–25 mg prednisone equivalent per day) than GPs (48/57 (84.2%), p<0.001). Among those not adhering to the recommendations, GPs mostly used initial doses >25 mg/day (7/57 (12.3%)), whereas non-adherent rheumatologists more frequently prescribed doses <12.5 mg/day (8/203 (3.9%)).
Concerning tapering, a similar proportion of GPs (42/58 (72.4%)) and rheumatologists (169/203 (83.3%), p=0.087) reported that their practice is to reach the recommended 10 mg prednisone equivalent after 4–8 weeks. Slower or faster tapering (not further specified by the questionnaire) were indicated by a minority of GPs and rheumatologists (slower: 7/58 (12.1%) GPs and 19/203 (9.4%) rheumatologists; faster: 9/58 (15.5%) and 15/203 (7.4%), respectively).
EULAR/ACR recommendations suggest tapering prednisone by ~1 mg every 4 weeks once remission has been achieved. There was no difference between GPs (35/58 (60.3%)) and rheumatologists (128/203 (63.1%), p=0.76) following this practice. Those not adhering mostly preferred faster tapering (rheumatologists 54/75 (72%); GPs 20/23 (87%), p=0.2). A higher proportion of GPs reported that ≥80% of their patients were off GC after 1 year of treatment than rheumatologists (32/58 (55.2%) vs 56/203 (27.6%), p<0.001) (table 2).
Table 2. Treatment of polymyalgia rheumatica with glucocorticoids; general practitioners versus rheumatologists.
| Characteristic | N | GP N=73* | Rheumatologists N=211* | P value† |
|---|---|---|---|---|
| Initial GC dose‡ | 260 | <0.001 | ||
| >25 mg/day | 7/57 (12.3%) | 1/203 (0.5%) | ||
| 12.5–25 mg/day | 48/57 (84.2%) | 194/203 (95.6%) | ||
| <12.5 mg/day | 2/57 (3.5%) | 8/203 (3.9%) | ||
| Adherence to initial tapering (10 mg/day GC3 after 4–8 weeks) | 261 | 42/58 (72.4%) | 169/203 (83.3%) | 0.087 |
| Alternative tapering (first 4–8 weeks)§ | 50 | 0.547 | ||
| Slower tapering | 7/16 (43.8%) | 19/34 (55.9%) | ||
| Faster tapering | 9/16 (56.3%) | 15/34 (44.1%) | ||
| Adherence to GC‡ tapering once remission achieved (reduction by~1 mg/months) | 261 | 35/58 (60.3%) | 128/203 (63.1%) | 0.759 |
| % PMR patients on GC‡ after 1 year | 261 | <0.001 | ||
| 0–20% | 32/58 (55.2%) | 56/203 (27.6%) | ||
| 21–40% | 12/58 (20.7%) | 70/203 (34.5%) | ||
| 41–60% | 8/58 (13.8%) | 42/203 (20.7%) | ||
| 61–80% | 2/58 (3.4%) | 27/203 (13.3%) | ||
| ≥80% | 4/58 (6.9%) | 8/203 (3.9%) |
A subgroup of participants submitted incomplete responses, which were evaluated when relevant. Denominators vary by question to reflect the total number of respondents, omitting missing values.
n/N (%).
Fisher’s exact test; Fisher’s exact test for count data with simulated p value (based on 10 000 replicates).
GC doses refer to prednisone equivalent.
Only including respondents not reporting adherence to the recommended taper regimen (see question above).
GC, glucocorticoid; GP, general practitioner; PMR, polymyalgia rheumatica.
Use of GC-sparing agents
Concerning the use of GC-sparing agents, almost all rheumatologists responded prescribing MTX for PMR (193/203 (95.1%)), while only a minority of GPs used the drug in this indication (14/53 (26.4%) p<0.001). Most rheumatologists prescribed MTX doses of >10 mg/week (150/194 (77.3%)), which was less common among GPs using MTX (7/15 (46.7%) p=0.013). Dosages of ≤10 mg/week were prescribed by 44/194 (22.7%) rheumatologists and by 8/15 GPs (53.3%, p=0.013). There were no differences in the route of administration (subcutaneous, oral or no preference) between rheumatologists and GPs (eg, oral administration 113/194 (58.2%) vs 8/16 (50.0%)), respectively p=0.239).
Experience with IL-6 receptor inhibitors for PMR (acknowledging that they are not included in the 2015 EULAR/ACR recommendations) was higher among rheumatologists (142/203, (70.0%)), than among GPs (1/53 (1.9%), p<0.001).
Follow-up of PMR patients
For follow-up of patients with PMR in the first disease year, rheumatologists more commonly preferred scheduled (as compared with on demand) follow-up visits than GPs (201/203 (99%) vs 42/51 (82.4%) p<0.001).
Rheumatologists mostly scheduled follow-up visit intervals between 9 and 14 weeks (104/203 (51.2%)) and less commonly between 4 and 8 weeks (63/203 (31%)), while the opposite was reported by GPs (9/51 (17.6%) and 24/51 (47.1%), respectively). Visit intervals of less than 4 weeks or more than 14 weeks were less common (rheumatologists 4/203 (2%) and GPs 5/51 (9.8%)).
Personalisation of treatment based on comorbidities showed no difference between rheumatologists (141/203 (69.5%)) and GPs (30/51 (58.8%) p=0.181) (table 3).
Table 3. Glucocorticoid-sparing agents and follow-up management of patients with polymyalgia rheumatica; general practitioners versus rheumatologists.
| Characteristic | N | GP N=73* | Rheumatologists N=211* | P value† |
|---|---|---|---|---|
| MTX for PMR | 256 | <0.001 | ||
| Not used | 39/53 (73.6%) | 10/203 (4.9%) | ||
| Regularly/occasionally used | 14/53 (26.4%) | 193/203 (95.1%) | ||
| Most frequent MTX dosage to treat PMR | 209 | 0.013 | ||
| MTX≤10 mg/week | 8/15 (53.3%) | 44/194 (22.7%) | ||
| MTX>10 mg/week | 7/15 (46.7%) | 150/194 (77.3%) | ||
| Preferred route of MTX administration | 210 | 0.239 | ||
| Oral | 8/16 (50.0%) | 113/194 (58.2%) | ||
| Subcutaneous | 5/16 (31.3%) | 67/194 (34.5%) | ||
| No preference | 3/16 (18.8%) | 14/194 (7.2%) | ||
| IL-6R inhibitors for PMR | 256 | <0.001 | ||
| Not used | 52/53 (98.1%) | 61/203 (30.0%) | ||
| Regularly/occasionally used | 1/53 (1.9%) | 142/203 (70.0%) | ||
| Personalisation of treatment according to comorbidities | 254 | 0.181 | ||
| Sometimes/rarely/never | 21/51 (41.2%) | 62/203 (30.5%) | ||
| Always/often | 30/51 (58.8%) | 141/203 (69.5%) | ||
| Personalisation of treatment according to weight/gender | 254 | 0.861 | ||
| Sometimes/rarely/never | 38/51 (74.5%) | 147/203 (72.4%) | ||
| Always/often | 13/51 (25.5%) | 56/203 (27.6%) | ||
| Follow-up care of PMR patients | 254 | <0.001 | ||
| On-demand visits | 9/51 (17.6%) | 2/203 (1.0%) | ||
| Scheduled visits | 42/51 (82.4%) | 201/203 (99.0%) | ||
| Interval of follow-up visits once in remission | 254 | <0.001 | ||
| <Every 4 weeks | 5/51 (9.8%) | 4/203 (2.0%) | ||
| Every 4–8 weeks | 24/51 (47.1%) | 63/203 (31.0%) | ||
| Every 9–14 weeks | 9/51 (17.6%) | 104/203 (51.2%) | ||
| >Every 14 weeks | 3/51 (5.9%) | 25/203 (12.3%) | ||
| Only when symptoms occur | 9/51 (17.6%) | 2/203 (1.0%) | ||
| Other | 1/51 (2.0%) | 5/203 (2.5%) |
A subset of 8 rheumatologists and 15 general practitioners (GPs) provided partial survey responses, which were included in the analysis where applicable.
n/N (%).
Fisher’s exact test; Fisher’s exact test for count data with simulated p value (based on 10 000 replicates).
PMR, polymyalgia rheumaticaIL-6R, interleukin-6 receptor; MTX, methotrexate.
Personalisation of treatment based on weight/gender showed no difference between rheumatologists (56/203 (27.6%)) and GPs (13/51 (25.5%)) p=0.861).
Subgroup analyses
The following subgroup analyses were conducted: comparison of responses from academic versus non-academic rheumatologists, fellows versus senior (=training completed) rheumatologists/GPs, respondents with clinical experience of >10 versus ≤10 years as well as according to the number of PMR patients regularly followed (rheumatologists ≤50 vs >50 patients/year; GPs ≤5 vs >5 patients/year). Below we report selected differences between groups; full data are available in online supplemental tables 3–9.
Academic versus non-academic rheumatologists
More non-academic than academic rheumatologists reported high adherence to the EULAR/ACR recommendations (42/45 (93.3%) vs 127/158 (80.4%), p=0.043); see online supplemental table 3. A higher percentage of academic rheumatologists personalise treatment according to comorbidities (117/158 (74.1%) vs 24/45 (53.3%), p=0.01).
Fellows versus senior rheumatologists or GPs
Among rheumatologists not following the recommended GC tapering of 1 mg/4 weeks, more fellows than specialists preferred a slower tapering (5/6 (83.3%) vs 16/69 (23.2%), p=0.006) (online supplemental table 4).
Among GPs, fellows are more frequent MTX users than seniors (6/11 (54.5%) vs 6/37 (16.2%), p=0.018). Besides, fellows reported personalisation of therapy by weight/gender less commonly than seniors (0/10 (0.0%) vs 12/36 (33.3%), p=0.044) (online supplemental table 5).
Subanalysis based on clinical experience with PMR
Comparisons between rheumatologists or GPs with >10 years versus ≤10 years of clinical experience are depicted in online supplemental tables 6, 7. In the subgroup of GPs, more respondents with ≤10 years of experience with PMR reported to personalise treatment according to comorbidities than those with longer experience (16/21 (76.2%) vs 14/30 (46.7%), p=0.046).
GPs visiting >5 patients/year used MTX more commonly than GPs with ≤5 PMR visits per year (7/15 (46.7%) vs 7/38 (18.4%), p=0.046; see online supplemental table 8).
Rheumatologists seeing >50 PMR patients/year were more familiar with the EULAR/ACR recommendations than those seeing ≤50 patients/year (50/55 (90.9%) vs 111/148 (75.0%), p=0.012; see online supplemental table 9).
Discussion
This study addressed the implementation of the 2015 EULAR/ACR recommendations for PMR in clinical practice. We observed broad awareness and uptake among specialists, while only a minority of non-specialists reported being familiar with, or adhering to, these recommendations. Nevertheless, most rheumatologists and GPs appear to use initial GC doses and tapering schemes that fall within the recommended range. GC-sparing agents are only occasionally prescribed by GPs but are routinely used by specialists. Identified gaps in the delivery of care for PMR underscore key challenges that need to be addressed, especially given the rapidly evolving therapeutic landscape and the availability of new treatment options.
The EULAR/ACR recommendations are still not widely disseminated among GPs, although the majority of PMR patients are diagnosed and managed in primary care.3 4 This gap may even be more pronounced, assuming GPs participating in this survey had a greater interest in PMR, interacted more frequently with experts in PMR and knew, therefore, more about recent developments in the field as compared with the average primary care physician. Management recommendations for rheumatic diseases are primarily disseminated through rheumatology conferences and specialist rheumatology journals, which may limit their accessibility and exposure among GPs.
A related finding is that rheumatologists managing a lower volume of PMR patients were less familiar with the recommendations than those with more frequent clinical exposure; however, this result is derived from a limited sample and should, therefore, be interpreted with caution.
Despite the apparent lack of awareness, most GPs intuitively used initial GC doses and tapering protocols within the ranges specified by the recommendations.5 In cases where GPs did not adhere, higher initial GC doses and faster tapering were applied. Although it is well recognised that initial prednisone doses >25 mg/day can lead to higher cumulative GC exposure and consequently more GC related adverse effects, the optimal GC tapering protocol remains a matter of debate.9 A proportion of PMR patients might be able to taper-off GC faster than specified by the EULAR/ACR recommendations.10 Conversely, some studies have reported an increased risk of relapses (and consequently higher cumulative GC doses in the long-term) if GC are reduced too quickly.9
Treatment personalisation and regular follow-up were considered important by both specialists and GPs. Most respondents preferred regular rather than on-demand follow-up visits, which is in accordance with the EULAR/ACR and recent T2T recommendations.5 11 Interestingly, GPs seemed to keep patients in closer loops than specialists.
GC sparing therapies are, as expected, only occasionally prescribed by GPs. Unlike MTX, IL-6R inhibitors are not included in the 2015 EULAR/ACR recommendations. Therefore, findings regarding these agents should be interpreted as an exploratory analysis of current clinical practice rather than as a measure of adherence to the recommendations.
We acknowledge that differences between rheumatologists and GPs may not solely reflect variations in quality of care but could also be attributable to differences in disease presentation, referral patterns and the availability of therapies across countries. Expertise in the semiology of PMR and its differential diagnoses, the diagnostic evaluation of patients with suspected PMR—including access to fast-track clinics, imaging modalities and specialised laboratory investigations—and disease severity are all likely to differ between patients managed in primary versus specialist care. This is particularly relevant when interpreting the use of methotrexate and IL-6R inhibitors as well as the persistence of GC therapy beyond 1 year.
GPs who prescribe GC-sparing agents most likely have a particular interest in PMR or were referring to follow-up prescriptions initiated by rheumatologists when answering this question in the survey. This result underlines the central role of rheumatologists in the management of PMR, particularly in patients with relapsing/refractory disease or in those at increased risk for GC-related adverse events.5 A key question is whether all patients who are candidates for GC-sparing agents (particularly biological therapies) are currently referred to rheumatologists or whether there is a referral leakage. Recent national management guidelines as well as international early referral recommendations suggest considering referral of all PMR patients to a rheumatologist to confirm the diagnosis, stratify patient’s risk and initiate treatment.2 12 Once patients are in stable remission and do not require a GC-sparing agent, they may be discharged to primary care. While some of the results of our survey support this approach, there might be challenges related to limited specialist resources and, consequently, unacceptable long waiting times for a rheumatology visit.13 An alternative approach could be to train and closely collaborate (eg, by regular boards or audits) with GPs who could eventually identify potential candidates for a GC-sparing agent.14 Expected challenges related to this strategy are the lack of interest/resources among primary care physicians as well as the small number of patients they regularly follow, resulting in limited experience with this disease.
In the present survey, we did not assess the extent or current models of collaboration between primary and specialist care, nor did we map patient pathways across countries. Although such information would have provided valuable context and complemented our understanding of PMR management, it was beyond the scope of the present study and should be assessed by future research.
In subgroup analyses, several notable differences were observed. For example, academic rheumatologists appeared to individualise treatment more frequently than their non-academic counterparts and consequently showed lower adherence to the 2015 recommendations. However, these findings—and others in this section—should be interpreted with caution, as they are exploratory and hypothesis-generating, given that no adjustments for multiple testing were performed.
The most critical aspect of our study is representativeness. We acknowledge that we have captured only a small sample of physicians involved in diagnosing and managing PMR. Nevertheless, our results may be cautiously extrapolated to a broader community given the wide representation of countries, fellows/specialists, academic and non-academic physicians. We made several efforts to reach rheumatologists and GPs worldwide by involving the EULAR GCA-PMR study group and using a snowball sampling approach.7 However, the number of respondents remained limited and may be biased towards physicians with a particular interest in PMR and GCA. Other methods of survey distribution such as publication in social media, professional advertisement or distribution via mailing lists from national societies were discussed,15 but ultimately not applied because the expected gain of relevant responses was low in relation to the additional efforts required. Besides, there are constantly circulating surveys via e-mail and social media on various topics resulting in respondent fatigue among professionals not directly involved in or partnering with a special interest community such as the EULAR GCA-PMR study group.16
Our study focused on PMR despite its widely recognised association with GCA. Although the 2025 recommendations address both Large vessel vasculitis (LVV) and PMR, the 2015 EULAR/ACR recommendations focused primarily on PMR.5 17 Moreover, in routine clinical practice, the management of PMR and GCA continues to differ substantially.5 18
This study was conducted shortly before the updated EULAR recommendations on LVV and PMR have been presented and should stimulate the development of strategies for their implementation.17 This has become a priority for all new EULAR task forces.6 One potential approach would be to more actively engage relevant interest groups and medical education coordinators and to disseminate recommendations through channels and events that effectively reach all key stakeholders. This may include but is not limited to communications via dedicated social media, international and national meetings, virtual training activities as well as existing learning portals. National guidelines may adapt EULAR/ACR recommendations to local populations and healthcare systems, thereby facilitating their acceptance and implementation at the national level. In addition, surveys such as the current may help monitor the progress and identify any gaps in implementation.19 Although the target level of implementation (eg, percentage of self-declared adherence to recommendations or other metrics) still needs to be defined, any critical aspects resulting from the analysis might trigger action points fostering implementation and ultimately improving clinical care of patients.
In conclusion, our survey shows the limitations in the implementation of existing EULAR/ACR recommendations for the management of PMR. Although specialty and non-specialty physicians frequently used appropriate GC doses and tapering, there was low adherence to recommendations by non-specialists. Use of GC-sparing agents, particularly biological agents, remains exceptional among GPs. This underlines the pivotal role of rheumatologists in the care of patients with PMR, particularly in those with relapsing or refractory disease or at increased risk of GC-related adverse events. Future guideline projects should define specific action points to support dissemination and implementation among all target users, for example, by involving interest groups and by communicating recommendations through dedicated media, educational formats and other channels.
Supplementary material
Acknowledgements
The authors are grateful to all physicians/HPRs who completed the survey, particularly the members of the EULAR GCA/PMR study group and all other professionals.
The authors thank the Department of Innovation, Research, University and Museums of the Autonomous Province of Bozen/Bolzano for covering the Open Access publication costs.
Footnotes
Funding: SES is funded by a Rheumatology Research Foundation Investigator Award, NIH/NIA R03AG082983, and AHA SFRN (24SFRNPCN1280228), outside of the submitted work.
Provenance and peer review: Not commissioned; externally peer-reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Ethical approval was not required because the study did not involve patients; all responses were anonymous.
Data availability free text: The data will be shared on reasonable request.
Presented at: Preliminary work was presented at EULAR 2026.
Data availability statement
Data are available upon reasonable request.
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Data Availability Statement
Data are available upon reasonable request.