PMRGCAuk

Should I switch from Prednisolone to Methotrexate?

I am currently on Prednisolone for GCA and have reduced to 4mg/day. However I am struggling to reduce any further. My Rheumatologist has suggested that I could try switching to Methotrexate to wean off the steroids but I am concerned about the possible side effects of Methotrexate.

Does anyone have relevant experience or comments?

My history with Prednisolone is that I was initially prescribed 40mg/day due to temporal pain symptoms that indicated GCA. The symptoms disappeared within 24 hours of starting the Prednisolone. After 3 months I had tapered the Prednisolone to 10mg/day but at this level, I re-experienced temporal pain and the Prednisolone had to be increased back to 40mg/day. I restarted tapering and after a further 3 months was down to 7.5mg/day. After a further 3 months I was down to 5mg/day and after a further 3 months was down to 4mg/day.

However, over the last 6 months I have struggled to reduce further. I cannot seem to reduce further but experienced temporal pain when tried “reducing from 4mg/3mg alternate days to 3mg daily

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The experts will be along with their advice regarding mtx, but if my math is right you appear to be at 4 mg after about 18 months of treatment? By any standards this is not a slow taper, indeed many would consider it quite rapid. Four mg is not a dose which is likely to cause many, if any, side effects and I personally think your doctor should be very happy with you and not pressuring you to reduce further while you still have evidence the disease is not yet in remission.

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if my experience of GCA is anything to go by, I'm not surprised you had to go back up to 40mg after a flare, that was jolly fast. I have tapered from 40mg at my own pace listening to my body/symptoms. As a result, after six months I'm still on 17mg, about to go to 16.5mg, with no incident but some close calls when I went too fast in the early months. I follow the rule found here that I reduce no more than 10% at a time and for a period of an absolute minimum of two weeks, so I can tell if it has worked before going on to the next reduction. I was told that two years is average for GCA to go into remission, so why are you being hurried along?

I would question why at such a low dose is the Rheumy wanting you to go onto a drug that has side effects that are not to be taken lightly. What is he afraid of that Methotrexate seems like the more benign option?

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It is beyond me why anyone wants a patient on a VERY low dose of pred to start another drug with its own layer of side effects and which neither replaces the pred nor is it guaranteed to reduce your pred dose. If methotrexate is to be used in GCA it seems to work better when started at the same time as pred. Not at the tail end. You are at a dose that is well below the physiological dose of 8mg and experienced and expert rheumatologists stop panicking about the dose at that point.

As the others have said, your reduction was pretty fast - and no wonder you had flares. I would decline politely.

If you can manage well at below 5mg, that is a dose that is similar to PMR doses and a recent article has demonstrated that patients on PMR doses do not suffer significant long term side effects:

practicalpainmanagement.com...

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