Steroid-sparing strategies in polymyalgia rheumatica: a systematic review and meta-analysis of tocilizumab with practical guidance for tapering

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition primarily managed with glucocorticoids (GCs), but prolonged GC use carries significant adverse effects. Tocilizumab, an interleukin−6 receptor inhibitor, has emerged as a promising steroid-sparing therapy for patients with relapsing or GC-dependent PMR. We conducted a systematic review and meta-analysis according to PRISMA guidelines to assess the efficacy and safety of tocilizumab in PMR. Four randomized controlled trials (RCTs) involving 317 patients were included in the meta-analysis, and one multicentre observational cohort was narratively synthesized to provide supportive real-world evidence. Relapse outcomes were categorized as short-term (≤ 12 weeks), medium-term (13–26 weeks), and long-term (> 26 weeks). Pooled analysis showed that tocilizumab significantly reduced short-term relapse rates (OR: 0.22, 95% CI: 0.12–0.41; I² = 22.5%) and medium and long-term relapse rates (OR: 0.19, 95% CI: 0.10–0.35; I² = 27.1%) compared to placebo. Tocilizumab also significantly lowered cumulative GC dose (SMD: -0.78, 95% CI: -1.21 to -0.23; I² = 84.5%). Severe relapse showed a non-significant trend favoring tocilizumab, and safety outcomes were comparable between groups (OR: 0.57, 95% CI:0.27–1.18; I² = 30.0%). The included observational study supported these results, demonstrating high rates of successful tapering (77% to ≤ 5 mg at six months; 97% at twelve months) with few adverse events. This updated synthesis supports tocilizumab as an effective steroid-sparing option in PMR and provides practical tapering guidance to assist clinicians in managing relapsing or GC-dependent cases.