What Is the Newest Treatment for Polymyalgia Rheumatica?

The newest approved treatment for polymyalgia rheumatica is sarilumab, sold as Kevzara, an injection for people whose disease keeps flaring as prednisone is lowered.¹ It doesn’t replace prednisone, which is still where treatment starts for almost everyone.² The real shift is that newer medicines aim to get people off steroids sooner rather than to cure the disease. Daily pills that calm the same inflammation are the next option on the horizon.³

How Sarilumab Works and Who It Is For

In PMR the body makes large amounts of IL-6, a chemical messenger that drives the aching stiffness in shoulders and hips.⁴ Sarilumab blocks that one signal. It is given as a 200 mg injection under the skin once every 2 weeks.⁵

Prednisone dampens the immune system broadly, which is why it touches blood sugar, bones, mood, and skin. Sarilumab targets a single pathway, so those steroid effects aren’t expected from it, though infection risk still goes up to some degree.

It is approved for adults whose PMR didn’t respond well enough to steroids, or who can’t get through a taper, meaning lowering the dose step by step.⁶ Flares are common, happening in about half of people, often once prednisone drops below 5 to 7.5 mg a day.⁷

In the main trial, 28% of people on sarilumab with a 14-week prednisone taper stayed in lasting remission after a year, versus 10% on a slow 52-week taper alone.⁸ Remission here meant no flare for the year while sticking to the planned taper. Fewer than a third reached that, so most people still flared and needed steroids again. The sarilumab group came off prednisone in about 3.5 months instead of a year. People on sarilumab also reported clearly better daily function and quality of life.⁹

A rheumatologist usually prescribes it, not a family doctor. You or a nurse inject it into the thigh or belly at home, and a nurse or pharmacist can show you the technique with the first dose from a prefilled pen or syringe. Prednisone continues at first and is tapered on a set schedule, with blood tests before and during treatment. Skipping doses to see if you still feel well can let inflammation creep back, so any change to the schedule should be agreed with your rheumatologist.

Why Getting Off Prednisone Matters So Much

Prednisone tends to linger. About 77% of people with PMR are still on steroids after 1 year, 51% after 2 years and 25% after 5 years.¹⁰ About 43% have a relapse in the first year.¹¹

The side effects add up. At least a third of people treated for PMR get a steroid side effect, and two thirds if weight gain counts.¹² Side effects rise with a starting dose above 30 mg and with the total amount taken over time.¹³ People averaging 5 mg a day or less were much less likely to get them.¹⁴

In older adults the usual problems are weight gain and a rounder face, higher blood sugar or new diabetes, thinning bones and fracture risk, raised blood pressure, cataracts, and easy bruising. Many creep in gradually, such as a thicker waist or trousers fitting tighter, so they are easy to blame on aging. Raised blood sugar often causes no symptoms at first and is found only through blood tests, which is why regular checks matter. Bone thinning is silent until a fracture, often in the spine or hip, so prevention has to start early. Some people also notice poor sleep, mood swings, or thinner skin that bruises with a small knock.

Total dose matters, not just today’s dose. Each month on steroids adds to the lifetime total, and every flare that pushes the dose back up adds more. A dose that seems small, like 5 mg, isn’t harmless when taken every day for years.

Tocilizumab and Methotrexate as Other Options

Tocilizumab also blocks IL-6 and is used for relapsing or steroid-dependent PMR.¹⁵ Across trials it cut relapses sharply and lowered total steroid use, meaning it lets you use less prednisone.¹⁶ In newly diagnosed PMR, 63% on weekly tocilizumab were off steroids and in remission at 16 weeks, versus 12% without it.¹⁷ In one clinic group, 80% on tocilizumab stopped prednisolone, versus about 28% on methotrexate.¹⁸

Methotrexate, a weekly pill, is the established older choice and lowers the total steroid dose people need.¹⁹ Started early at 25 mg a week, 80% were off steroids and in remission at one year, versus 46% without it.²⁰ In another trial it brought fewer flares, with side effects no worse than placebo.²¹ It is taken once a week, never daily. A folic acid supplement is usually given to reduce side effects, and because methotrexate takes weeks to work, prednisone continues meanwhile.

2025 European guidelines say to start prednisone at 15 to 25 mg a day, and they recommend adding an IL-6 blocker for selected patients.²² An older biologic, infliximab, didn’t help when added to prednisone.²³

Day to day, the options differ. Methotrexate is a cheap weekly pill with regular blood tests. Tocilizumab and sarilumab are injections and much costlier. Not every country approves tocilizumab for PMR, so it may be prescribed off-label. Doctors often try methotrexate first when cost or insurance is a barrier.

None of these drugs removes PMR. They reduce how much prednisone is needed to keep it quiet, and many people in the trials still needed prednisone for some time.

Whether a second drug gets added after a flare usually depends on how often you have flared, how high the dose was when it happened, and what side effects you already have. Diabetes, osteoporosis, or other conditions that steroids worsen strengthen the case for adding one sooner. Your liver health, infection history, and other medicines also affect which option is safer for you.

Risks and Cost of the IL-6 Blockers

Across trials, IL-6 blockers didn’t cause more side effects overall than placebo.²⁴ In the first year, though, hospital-treated infections were about twice as common as with older immune medicines.²⁵ Prednisone itself raises infection risk, so weigh this against longer steroid use. The risk was highest early on, so watch for symptoms in the first months. Serious liver injury and bowel tears were rare, under 1 per 100 people a year.²⁶

Call your doctor promptly about fever, cough, or burning urination. IL-6 blockers can hide fever and lower inflammation markers in the blood, so an infection may look milder than it is. Tell any doctor or dentist that you take one, and get vaccinations up to date before starting.

Blood counts and liver tests are checked before starting and at intervals afterward, because these drugs can lower white cells or platelets and raise liver enzymes. Cholesterol can also rise, so lipids may be checked a few months in. These tests catch problems before you feel anything, so keeping appointments matters.

In Canada sarilumab costs about $19,400 a year per patient at list price.²⁷ Insurance approval usually depends on showing that steroids alone failed. Keep a record of each flare and the dose it happened at, note the side effects you’ve had from prednisone, and ask about manufacturer assistance programs.

JAK Pills on the Horizon

JAK inhibitors are daily pills that block switches inside cells that inflammation signals use.²⁸ In one small trial with no oral steroids, about 78% on baricitinib had low disease activity at 12 weeks, versus 13% on placebo.²⁹ Low disease activity at 12 weeks is a short-term measure and says little about whether people stay well after stopping steroids. Tofacitinib worked about as well as a steroid taper in newly diagnosed people over 24 weeks.³⁰ These studies are small, and a larger baricitinib trial is still under way.³¹

Sarilumab blocks the IL-6 signal outside the cell, while JAK pills act inside the cell on switches that several inflammation signals share. They dampen more than one pathway at once, which also affects more of the immune system.

You can’t get a JAK pill for PMR as a standard treatment now. They’re approved for other conditions like rheumatoid arthritis, so use for PMR would be off-label, and they carry warnings about clots and infections in older adults. If you’ve failed other options, ask about clinical trials.

Protecting Your Bones While You Treat PMR

Most people with PMR take over 5 mg of prednisolone for more than 3 months, long enough to threaten bone strength.³² People with PMR who exercise have denser bones.³³ Strength training protects hip bone better than aerobic exercise alone.³⁴

Bones respond to load, so walking, climbing stairs, and carrying light weights signal them to hold on to strength. Swimming and cycling are good for fitness but load the bones less, so they work best alongside weight-bearing activity. Lifting light weights or using resistance bands adds the strength work. Balance exercises reduce falls.

Begin gently with short sessions on the days when stiffness is lowest, often later in the morning after warming up. Increase weights and time slowly over weeks, because a sudden big jump can aggravate sore muscles. Ask about a referral to a physiotherapist, who can design a program that fits your pain level and tell you which movements to avoid.

For your next appointment, consider asking:

Am I a candidate for a steroid-sparing drug?
Should I have a bone density scan?
Do I need calcium, vitamin D, or bone medicine?
What dose did my last flare start at?