Prednisolone -v- Methotrexate ?

[paah]

I have been on Preds now for 18 months , starting with 50mg's / day and now down to 11 mg's /day - with some difficulty might I add. My Rheumatologist now wants to introduce methotrexate so that I can cut back on steriods, from what I have read it does not seem a whole bundle of fun . I will let you know how I react.

[PMRpro Ambassador]

If you had GCA to start with - which judging by the starting dose you did - on the basis of the several others I have known who have had similar experiences I would have thought getting to 11mg pred from 50mg in 18 months was quite acceptable. I have replied to Kate Gilbert at length on this thread: "Does anyone have insights concerning the use of methotrexate along with a 5mg. daily dose of prednisone?"

In the same situation I personally would ask my rheumy to allow me to try a very slow further reduction but without MTX to see how I progressed. I have a friend whose consultant was adamant she should use MTX when she was already down from 60mg to about 15mg or even less. She demurred and is currently down to well into single figures after less than 2 years by reducing at 1mg at a time. It is well known (reported frequently in the medical literature) that flares are common in the first 18 months of GCA - and the most common cause of flares is reducing too fast or too far.

IF you are one of the few who has no or few side-effects from MTX then fair enough but if it makes you ill I question the point. My reading of the literature does not suggest there is a lot of evidence to support its effect. My rheumy here in mainland Europe is adamant that there is very little evidence for its role in PMR and none at all in GCA. What I have read of the existing studies does give me the impression that they were not particularly good, often poorly controlled and there is no way you can compare the results of different studies since the basic criteria were not similar enough.

That is my personal opinion - but it is one I'd like to defend!

[Polywotsit PMRGCAuk team member]

Yes, like PMRpro I'm inclined to think that if you have got down from 50mg to 11mg in 18 months you are doing quite well. If you can reduce very very gently from now on, at not more than 1mg a time, and as part of a very gradual process, I can't see any obvious reason why you should need or want to try anything else as well in order to come down quicker. It's not as though you are one of those cases where you have been coming down, then flaring, then back up again, then a too-rapid drop, for several years.

[Hidden]

I would ask your Rheumatologist 'what are his grounds for using Methotextrate' when you have reduced successfully and I gather without the two flares (also mentioned in the BSR Guidelines on Diagnosis & Treatment of GCA )and not uncommon at that within the first 18 months to 2 years and you are doing brilliantly to have got as far as you have in such a short time. So why rock the boat.

Pred comes with side effects (all 82 of them and nobody gets them all and they are all well documented). Methotextrate also has side effects. So add them together. If Metho was a cure and not just a steroid sparing agent then great. Ask him if you will get off the pred altogether and then just have Metho. And if just Metho for how long, will it make a difference to the remission coming along. Because it is not a cure, there is no currently no cure.

It is a very personal decision and one that you must make when you have all the facts as they are currently known.

I also echo Kate, slowly slowly and no more than 10% at a time. 10mg and 5 mg are sticking points and must not be rushed. There is a pattern to follow, devised by patients for patients. A PM if you want to look at it.

[Hidden]

I have been on preds now for 11 months, due to PMR, starting at 60 mg am now down to 12 mg as my doctor continues to nag me that I am not reducing them quickly enough, but I have tried and I can't get below 12 mg, and would really like to increase them a bit more, to ease some of my pains, but if my doctor won't prescribe me more, I have no choice, can't change doctors as I live in a small village and have no choice, 3 months ago I developed a DVT in my leg, and now take warfarin, so not sure if that's why he wants me to reduce my preds even more, I have weekly inr tests, he is not one to explain things to his patients, I get most of my information from here, reading what others do and say,

[paah]

I don't think your GP is being very tolerant , to go from 60 to 12 mg's in 11 months I think is very rapid. I have gone from 50 to 11 in 18 months but very often I have to increase the dosage when I have a flair-up, then that takes a week or two to reduce.

I have several friends in the area, we don't all go to the same GP, we all find that dosage is governed by us, ie self regulatory and that seems to work

[Whittlesey]

Hi Paah, I have GCA and started w/100 mgs of prednisone. Got very sick. Changed to methylprednisolone and over three months reduced to 5mgs of medrol a day. I started on methetextrate in the second month of this, as a "steroid sparing agent" and I also taking aspirin. I have been able to stay on the 5mg's with only two flares of the GCA on this. I feel better with this combination. At first the methetextrate made me feel dizzy, weak, nauseous, but not so much any more. And it takes care of the intense headaches that were hard to treat. I take it by injection intramuscularly every week. I started at 10 mgs and moved up to 20 mgs and it helps a lot. When I had the cartoid dissection they gave me 20mgs of medrol and two aspirin a day, which I took for four days. inflammation was down and I worked down to the 5 mg's w/methetextrate and aspirin. There have been some studies in the U.S. which I have read, which conclude the methetextrate, aspirin and a small dose of medrol can keep GCA under control. True they are not the best studies, but they do feel this a way towards less medrol. Many of the experts I have spoken w/ in the U.S.. agree with this. Would recommend trying it, if you can deal with and eventually get over the symptoms from methetextrate, it may be a help. wishing you luck and all the best w/GCA. all my best, good health, Whittlesey U.S. NYC

[polkadotcom]

I'm getting a little concerned about the increasing incidence of GP's giving methotrexate apparently at the drop of a hat. I was put on methotrexate when I was stuck on 17.5mg of pred, but I had been on steroids for some years at that point and was developing obvious problems with it - spontaneous bruising for one.

It worked for a year allowing me to reduce to 2.5mg but then also allowed a serious GCA flare to creep in, which agrees with the findings in some studies which have shown that it simply doesn't work for GCA in the first place. As the flare subsided it became clear that it now wasn't working on any level and I came off it after two years.

I should also make the point that in the earlier years it was suspected that PMR was morphing into something else but the tests made very little sense (that's me!) and I was left with a label of polyarthritis. It's possible that the methotrexate (I was on the highest dose given as a steroid-sparing agent, 25mg weekly) worked on this condition, not PMR or GCA, and gave me relief in that way.

Whittlesey, I think that Medrol is a little different to Prednisolone and for some is difficult to tolerate compared to Prednisone? That might make a difference, too.

[Hidden in reply to polkadotcom]

I am sure that Methotrexate can only be prescribed by a hospital consultant so they are the culprit not GP's! Certainly it is up to the GP surgery to arrange monitoring blood tests and check the results.

The mindset from Dr's is that long term prednisolone is not a good idea because of the side effect profile. I am not defending this position but it is the reason why they are so desperate to try steroid sparing meds.

The really sad thing from my point of view is that the treatment of ANCA associated vasculitidies has been transformed with the advent of biologics with PMR/GCA and other large vessel vasculitis lagging behind due to lack of research/ interest.

[polkadotcom in reply to Hidden]

Quite right, Keyes, my typo, I should have put 'medics'. The reason that PMR/GCA has lagged behind others for research is that until recently it was perceived as a condition which struck the elderly (and by that I mean age 75 and upwards) and as such, was not worth researching in terms of money. As it is now being diagnosed (mainly because the baby boomers have arrived and in many cases are still working age) at earlier ages it has caught the interest of those with funding and interest to spare and research is beginning. There is definitely a foot in the door now.

As I am steroid dependent I fully understand the need for alternative or add-on treatment where long term steroid use is predicted and I understand that the biologics may well prove to be as effective as they have been in RA. When I started methotrexate I was hopeful and as I have said, it worked for a while. The question in my mind has always been - exactly what did it work on for me? Not GCA, it let that slip in unnoticed. PMR? Well possibly. Other rheumatoid conditions? Probably.

I haven't had the opportunity to try any other DMARD for these conditions, but I am always willing!

[Narducci]

Had been on prednisolone for around 18 months and was supplemented with Methotrexate. No bad side effects and it has enabled me to drop down to 8mg of Pred a day. Just need to keep an eye on any possible adverse effects on liver which is done by monitoring blood tests. So far, touch wood, no problems and feel better with lower dosage.

[paah in reply to Narducci]

Many thanks for your response, I appear to be on a similar regeem to your self, fortunately I am monitored by a fairly switched on Rheumatology dept at our local hospital and have weekly blood tests.