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Methotrexate and Ibuprofen

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.

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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?

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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.

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I reviewed my medical records. I was diagnosed with PMR for one year when mtx was introduced. There was 15 years of uveitis and reactive arthritis prior to this time so maybe mtx was indicated for that reason. Anyway, all was well at 10 mg prednisone and ibuprofen PRN --- no other medications.

For some reason naproxen was prescribed daily instead of ibuprofen PRN. Mtx 15 mg, folic acid, omeprazole were started along with the prednsione. Over the next two years, mtx was gradually increased to 30 mg and naproxen was changed back to ibuprofen.

I won't go into details but the highlights were, hypertension in the neighborhood of 200/100, LVH with frequent PVC's, fatigue, elevated liver enzymes, nausea, vomiting, diarrhea, along with pain and prednisone doses up to 60 mg. Then an unfortunate infection occurred and I think I told you about the extensive bilateral PE which was called "unprovoked." but the suggestion was that it was prednisone related.

Methotrexate was stopped and prednisone was tapered back to 10mg during the next 2 years. Then we moved on to a trial of leflunomide.

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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.

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It seems that everything was fine for the first year. Prednisone was decreased from 10 mg to 5 mg. Mtx was increased from 15 mg to 25 mg.

Then uveitis recurred and treated with the usual 40 mg of prednisone and tapered over 2 months back to 10 mg. At the next rheum visit it was clear that mtx was increased to 30mg for recurrent uveitis and increasing pain. Instructions were to taper back down to 5 mg pred. There was an interesting note that read, "tolerates mtx, OK to take NSAID to help prevent uveitis" and cited some research.

That's when things started to spiral out of control on multiple fronts including the hypertension. Three blood pressure medications were added to the mix and more pain medications. Prednisone was increased to 60 mg with a rapid response. The visit at that time stated "symptoms behave like PMR". Soon thereafter, a nasty bout of norovirus occured and was followed by the PE.

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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

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Ooh - thanks, I'd forgotten that!!

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Ibuprofen and methotrexate ... maybe that was why I had a terrible time with methotrexate even at a low dose. My liver couldn't handle them together.

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

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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...

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

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

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Thank-you. I should have read that before starting methotrexate with NSAIDs and prednisone. It explains a particularly bad period of time in my life.

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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

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I need to review that in my medical records. My rheum wanted me to reduce pred while increasing mtx. That for sure didn't work. I bet I added ibuprofen myself as the pain increased.

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

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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........

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

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It’s good practice!

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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.

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

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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.

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Wow! Good On Them!

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I've edited my last response....

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

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The only reason, in my opinion, is that physicians absolutely hate that any of their patients are taking prednisone long term. The reason for trying other medications as a prednisone sparer is that almost any other medication is deemed to be "safer" than ANY dose of prednisone long term. I don't agree when PMR pain is a pressing problem in the present.

It is true that side effects from the other "safer" medications are usually temporary and go away when the drug is stopped. Side effects of prednisone tend to be permanent. The one explanation that made some sense to me is that oral prednisone has systemic effects. Prednisone taken long term may lead to adrenal suppression which could become permanent. Other protential side effects like cataracts, diabetes, and osteoporosis can be corrected somewhat but still tend to be long term problems. The physician who prescribes prednisone shares some responsibility for these outcomes regardless of why prednisone was prescribe in the first place.

A life of pain is not a great option either.

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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.

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I'm just repeating what a number of doctors have told me. I left out avascular necrosis which was particularly scary to me when it seemed like a doctor was threatening me with that. After 25 years of prednisone use, I personally don't have diabetes, osteoporosis or avascular necrosis. However, I have personally witnessed and took care of many people who did develop those kinds of side effects from prednisone. It is for this reason that I am reluctant to advocate for long term prednisone use even though I have used it long term myself. I too, wouldn't want to be partly responsible for someone's use by saying that prednisone is a "safe" medication.

As for cataracts, my experience was rapid onset and essentially blind in one eye in my first year of prednisone use in my late 30's. It was thought that uveitis caused the problem in my left eye. Uveitis couldn't be blamed for my right eye which occurred less than a year later.

Since prednisone is the only current option for PMR, the choice becomes pain or no pain. Therefore, whether to take prednisone or not is an easy choice. The issue of adrenal insufficiency did catch me off guard because nobody ever told me it was likely until recently.

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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.

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You're damned if you do and damned if you don't.

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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.

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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

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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.

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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.

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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.

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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?

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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!!!

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