Methotrexate and Ibuprofen

[Joan-E-D]

I need to understand what my rheumy is suggesting. I'm tapering down to 4 mg pred. (having had PMR for two and a half years), but he wants to put me on Methotrexate as a steroid sparer. Does that mean that eventually I'll be on Methotrexate to control the PMR instead of Pred? What are the advantages? Also he suggested I took Ibuprofen for pain relief and Omerprazole to prevent stomach ulcers. If Ibuprofen works for PMR why are we prescribed Pred. when we get PMR? I'd be grateful for any answers. I'll be going to my GP next week for the results of my blood tests and will ask her what she thinks too, but I feel I need to understand more before I decide whether to follow my rheumy's suggestions when I see him in 2 months time. Many thanks.

[DorsetLady PMRGCAuk volunteer]

Hi,

Personally I don’t see the reasoning in adding in another drug when you are at such a low level of Pred. It’s usually prescribed for people who are having problems reducing, so unless you are, then don’t go down that route. The side effects from 4mg of Pred are nothing compared to MTX.

Ibruprofen will NOT lessen the effects of PMR, Pred’s the only tried and tested drug, but at 4mg if you have anything else going on - say arthritis they may help.

Omeprazole is usually prescribed when you start Pred, but if you’ve had no problems so far, you may be one of the lucky ones that doesn’t need it.

Strikes me, he’s one of those Rheumies who still believes PMR goes away in 2 years, actually more recent studies shows its nearer 6 years.

rheumnow.com/video/dr-kathr...

I would say you’ve done pretty well to get to 4mg without problems - so why change things now?

[PMRpro Ambassador]

I'm sorry but I fail to understand why anyone wants to use methotrexate (mtx) for a patient who has already got to such a low dose. If at all, it should be used at higher doses if patients struggle to reduce below, say, 10mg. But it is crazy to put a patient who has got to 4mg ater 2+ years in a disorder that lasts, on average, nearly 6 years. Methotrexate will not replace the pred for most people, it may let them manage on a slightly lower dose, but that is at the risk of an added layer of side effects. And at this stage, at 4mg pred, it is returning adrenal function that is the limiting fact over speed of reduction, often reducing very slowly as we keep on about on the forum will achieve just as much, with no side effects. If mtx managed PMR symptoms they would use it first line - not pred. But pred is the mainstay of PMR management. mtx sometimes works for some people - probably because they have a form of PMR that it will work for or it isn't "just" PMR.

If you have PMR pain then that is a sign you need a bit more pred - and ibuprofen is unlikely to help much, it doesn't for most people. I have to say, your rheumy wouldn't be my rheumy after trying to persuade me to add 3 extra medications, all of which have considerable side effects of their own and no-one really knows how using all that lot together interact. Prof Sarah Mackie is hoping to get funding to study the use of mtx in PMR - because so far there is no good evidence it works. One study found it did allow patients to manage on a lower dose of pred after about a year - but when they followed up 5 years later they found there had been no difference in the pred side effects suffered. Which rather begs the question: "Why bother?"

A new study found that the low doses of pred used in PMR are not problematic:

practicalpainmanagement.com...

medpagetoday.org/rheumatolo...

except for cataracts - which are easy to deal with anyway.

I have said for some time that it is possibly worth trying mtx, for some people it doesn't cause problems and if that is so it is worth persevering to see if it does help. I tried it last year - and for me it was awful. My hair started falling out in chunks within a week, I had muscle aches and joint pain, bruised and had other so-called pred side effects I had never had including hunger and I put on 1kg in a month. I experienced fatigue that was worse than anything I had had with PMR or pred - and after 4 weeks I could barely put one foot in front of another. We were going to S Korea for a meeting - I stopped or I would never have managed the trip and I never started again. It took a few months for everything to settle down. Luckily my rheumy accepts my decision.

If you put methotrexate in the search box at the top right you will find older threads about it with other people's experiences.

[Hidden]

I don’t have much to add to Dorset Lady & PMRPro other than l started Methotrexate when l kept having to go back to 20mg Pred.

As DL says if you have other arthritic pain ibuprofen may help that but if it’s PMR then a slight increase of Pred is often the way forward.

For Info - you cannot take ibuprofen with Methotrexate.

MTX a is a powerful drug & using it to reduce you from 4mg Pred seems a rather extreme measure unless you are showing signs of Rheumatoid Arthritis which then it is of great value.

Kind Regards

MrsN

[PMRpro Ambassador in reply to Hidden]

Ooh - thanks, I'd forgotten that!!

[Hidden]

I was on Diclofenac & that had to be stopped also when l started Methotrexate.

[PMRpro Ambassador in reply to Hidden]

When I think about it - that guy is suggesting pred, mtx and ibuprofen - all tough on the liver, plus omeprazole that has gastric effects and adverse effects on bone density . But is panicking about pred at a low dose which has been shown to have minimal long term effects...

[Hidden in reply to PMRpro]

If you read they Patient Information Leaflet it specifically states NOT to be taken with Ibuprofen.

medicines.org.uk/emc/files/...

[Longtimer in reply to PMRpro]

I'm thinking we have no chance with GP's like that suggesting such things!......quite worrying really.....

[Hidden in reply to Longtimer]

I always stuck to the same Pharmacy & questioned every New ‘Scrip in case of possible Contraindications. We really do have to advocate for ourselves.

I’m now in the process of getting to know my New Pharmacist........

[Longtimer in reply to Hidden]

Yes, a good idea for us....I Check as well if they aren't too busy!

[Hidden in reply to Longtimer]

It’s good practice!

[Telian in reply to Hidden]

Having a good Pharmacist is key, ours is very efficient.

If it's a new med they ask if you want a phone call in a week or two to see how we're getting on with it- they always have time for any queries, it there's a problem they will follow it through with the GP if you want them to. I trust them implicitly.

[Hidden in reply to Telian]

That’s Excellent Telian, an Independent Pharmacist or part of a Group?

[Telian in reply to Hidden]

Morrisons! I like them because they are the same staff they have two pharmacists that cover for one another, I get a real personal service, they will be a hard act to follow when we move.

[Hidden in reply to Telian]

Wow! Good On Them!

[Telian in reply to Hidden]

I've edited my last response....

[SheffieldJane]

You seem to be doing pretty well without a steroid sparer or Omeprazole. Drs don’t make promises about Methotrexate because it is a hit and miss affair for PMR. At best your side effects and symptoms are minimised whilst you reduce Pred more quickly. At worst you introduce a new powerful drug with nasty side effects. If you have been fine up to now without Omeprazole, I wouldn’t start it now that you are on such a low dose. Maybe he was thinking about the additional adverse effects on your digestive system if you start using Ibuprofen as well? Incidentally, I wouldn’t take any NSAIDs with Pred.

Look up the side effects of these drugs.

Some doctors are fixated in the belief that PMR should only last 2 years.

Recent American research has shown that the duration is more like 6 years. Making you ahead of the game by some margin. It it was me, I would keep calm and carry on. Unless there are other medical factors in your case.

[DorsetLady PMRGCAuk volunteer]

Actually I don’t know there is a ‘safer” option to Pred is there - they all have side effects of some sort, and are they more temporary than Pred side effects.

I would agree that adrenal insufficiency can be a permanent problem, but diabetes can be reversed and osteoporosis is not always a given, and who’s to say your cataracts wouldn’t have been affected anyway. One study did concluded that more may be picked up because patients on Pred had their eyes screened more regularly than the general public.

Doctors seem to have a greater fear of Pred than any other medication, and I just wonder why - they all have their good and bad sides.

[DorsetLady PMRGCAuk volunteer]

Personally I would say no medication is “safe” - but sometimes we all have to take a “less than safe” option in life!

Hobson’s choice.

[Hidden]

Actually you should have been told, not only by your Rheumatologist but your Pharmacist as well.

But the main thing is, as you know now it explains a bad period in your life.

Onwards & Upwards now.

All The Best.

MrsN

[Daffodilia]

I believe the steroid helps the body fight the immune system which is causing inflammation in the muscles which causes pain. I use ice packs instead of ibuprofen - hour a day when watching tv - effect seems to last well

[PMRpro Ambassador]

I imagine the mtx may well have been related to the uveitis and reactive arthritis. How long were you on the first mix before the hypertension ect manifested? If I were in your place and now good at 10mg - nothing would persuade me to go on anything again. I'm very happy at 15mg with this flare. I know where I am and things are nicely balanced. Could be better - but I'm reluctant to take the risk of them being worse.

[Telian]

I agree with what others have said that you don't need to go down the MTX road at this late stage. I haven't taken it but I listen to others that have. I am on 4mg Pred and it can get harder to reduce as you get lower, try a .5mg reduction from now on, I do as 1mg reductions cause me a lot of grief.

If you do need something for your stomach then Ranitidine does the same as Omeprazole but is milder on the stomach. Whilst you don't really need it for the Pred I would take it if I was taking Ibuprofen -which is no use for PMR but if it helps the arthritis..... you have to monitor your pain by stopping it for a few days. Best wishes.

[Joan-E-D]

Thank you all so much for your comments, advice and links. I don't have anything else wrong, only PMR as far as I know. My reduction has had a few hiccups where I had to go up for a little while or stay on the same dose for a bit longer than DSNS, but mostly its been downwards. That's why I was so shocked at the rheumy's advice to go on Methotrexate, to which I told him I wanted to wait until I see him again in May, before considering trying it . He told me to take Ibuprofen if the pain got bad whilst I was reducing rather than slowing down or stopping the reduction. That doesn't seem sensible for PMR either, from your comments. No wonder I don't feel confident about him. I'll continue to reduce for now and hope I don't have to have a show down with him when I see him in May.

[PMRpro Ambassador in reply to Joan-E-D]

I would sit down with your GP and discuss the entire thing. I definitely would NOT be using ibuprofen and I would be very doubtful about mtx at this stage. Your GP may be happy to look after you - which he can if you aren't on mtx.

[Alsdouble]

I have LOADS of prednisolone 1mg, 2, 2.5 5...Shed loads of them. My local doctors leave me to it. I also take calcium and alendronic acid of course. My PMG is under control, for over a year and a half, also use pred for my COPD. Currently on 3mg per day but I can see a day when it will be zero. (Will the doctors guide me? Probably not) I understand I have to take it... gently. Aren't doctors wonder ful?

[hey_suz]

Hi and wonderful news on you tolerating 4mg of pred! I was started on MTX about a year ago for new onset RA (Im also almost through my PMR run on 3mg pred for that) I agonized over starting MTX and I ended up doing it due to unmanageable knee swelling. Good news is I do very well on 15mg injectable MTX. Im writing this to speak to MTX being tolerated and if anyone ever has to give it a go, I can say it gave me my ability to walk back. I take Nutrafol vitamin for any hair loss, which I have none of.

Good luck!!!

[Visby]

My gp told me not to take ibuprofen with methotrexate or pred , now just on pred as methotrexate didn’t help me at all