Methotrexate and prednisone

[Amkoffee]

I developed severe osteoporosis and broke multiple bones due in part to the steroid use. So it is for this reason that my rheumatologist and I are trying to find a suitable replacement for prednisone. And of course we all know there isn't really one. I'm allowed to take 5 mg everyday and up to 10 mg if I'm having a particularly bad day. This really doesn't do much for my pain, stiffness and fatigue. I've been on Methotrexate for 4 weeks and I'm not finding any improvement yet. I've already tried two different kinds of DMARD with no help. My sed rate and CRP are elevated of course. I also have osteoarthritis throughout my spine and in my hands. How does methotrexate work with prednisone?

[MrsNails]

Hi Amkoffee

Sorry, l’ve not been around today & am just settling down but thought a quick reply may help.

Methotrexate (MTX) is usually added as a ‘Steroid Sparer’ in the hope you get a better result from the Prednisolone ie you can reduce the dose.

But it would seem your Rheumatologist is adding this in the hope it will improve your pain? MTX can take up to 12weeks to become fully effective, so that may give you some hope. But generally it’s the Pred is that makes the difference....

I will reply in more depth in the morning, what dose of MTX has he put you on?

Kind Regards

MrsN

[Amkoffee in reply to MrsNails]

I would appreciate any information you have. I'm taking 0.6 ml by injection once a week. I have stomach problems and she thought the pills might bother my stomach. And I already knew how to give myself an injection so it just made sense.

[PMRpro Ambassador in reply to Amkoffee]

The volume of dose in an injection tells us nothing, it depends on the concentration in the solution.

[MrsNails in reply to Amkoffee]

Sorry it’s taken me a while to reply, not so very sparkling today ☹️

Methotrexate is used as a Steroid Sparer they are not quite sure how it works but it is effective for some people but not others; l have benefitted from it in the past but now am struggling & not improving sufficiently....

Are you based in the U.K.? As PMRPRO has explained Actemra (TCZ) can be used in the right circumstances but only for GCA in the U.K. however in the USA the rules are different.

Very Best Wishes

MrsN

You can read my Story with you click on my Avatar & scroll down my Profile.

[dmart7 in reply to MrsNails]

Methotrexate is prescribed as a steroid sparer, allowing the dose of steroid to be reduced. It will take longer than four weeks to work. . But lLike so many things with PMR, this is all a bit tricky. The evidence on the efficacy of Methotrexate for helping PMR (and GCA) sufferers is ambiguous. Where positive results exist, they cannot be dissociated from the possibility that the improvement detected is actually against other arthritis conditions (for which there is better proof of efficacy). There's the rub. Rheumies often suggest that we have other arthritis conditions, and you could argue that prescribing Methotrexate is based on that suspicion, rather than a confidence that it will act against PMR. My personal interpretation of this situation is that if symptoms are unambiguously those of PMR, then Methotrexate is less likely to help. If there are other arthritis-type symptoms (eg. not just shoulders and hips), then Methotrexate may be worth a try.

[Amkoffee in reply to dmart7]

My doctor thinks I have RA despite a negative blood test. I definitely have osteoarthritis in many joints in my body including my back and neck. That alone causes me a great deal of pain as well as other issues of my back and neck. My PMR pain when it's at its worst it is absolutely very noticeably different. I had been taking Excedrin for 2 years and when I stopped taking it my PMR symptoms came on hard, and painful. Up to that point I had not been taking Prednisone for about 6 months. Apparently the aspirin in Excedrin was helping the inflammation but my inflammation markers were still very high. Methotrexate is only good for inflammatory arthritis not for osteoarthritis, I don't believe. I just need something to help because I am in so much pain everyday, it's crazy. I have a pain pump which pumps morphine into my spinal fluid that helps a lot with my back pain.

[yorkieme]

I am a new learner on this site since January this year so much of what I say needs to be checked against more experienced contributors.

I moved to Methotrexate (15mg/week,) and Folic acid four weeks ago around the same time as you. My rheumy' produced a report in which she stated that the initial high dose Pred' had caused me quite considerable damage and that she was almost certain responsible for my broken T4 vertebrae.

She decided to reduce Pred' by using what is called a sparer,in this case Methotrexate,but I have come to understand that it isn't a replacement nor will it mean that I will come off Pred' completely. Neither are pain killers.

The more knowledgeable contributors will be along at some point to either correct me or provide further information.

Good luck and all the best.

[DorsetLady PMRGCAuk volunteer in reply to yorkieme]

You are correct- and well explained. But there is no reason why you shouldn’t get off Pred eventually once your PMR is in remission.

[SnazzyD]

Did they put you on any bone meds?

[Amkoffee in reply to SnazzyD]

Yes I'm on Prolia every 6 months

[CJ-pmr15]

I struggled to get below 10 mg pred for 4 years. My rheumy suggested trying mtx. I started off on 10 mg, and stayed on that for 12 weeks then increased to 15 mg for 12 weeks before trying to reduce the pred. I was still unable to reduce the pred, so mtx was increased to 20 mg. again, I had to wait 12 weeks before reducing. I have been reducing very slowly and have managed to reduce to 6.5 mg pred. I’ve tried to get to 6 mg twice , but have had flares. So am sitting on 6.5 mg for a good few months before trying to reduce further. I’ve been on 6.5 mg for several months but only within the last couple of weeks have noticed a reduction in some steroid side effects.

I’m afraid this is a long journey. My total time on mtx is about 18 months, and my pred reduction 3.5 mg.

[jinasc]

I notice you are in the US. There is an alternative you can try, called Actemra. It was licensed by the FDA very quickly for use in GCA and it can work in complicated cases of PMR.

You need to discuss this with your Rheumatologist.

[Amkoffee in reply to jinasc]

I am going to ask about it. Thank you.

[PMRpro Ambassador]

There IS almost a replacement for pred - it is a biologic called tocilizumab, brand name Actemra. For 50% of patients it gets them off pred altogether within 6 to 12 months from starting on a high dose and for the rest it reduces their pred dose significantly. This is because there are 3 different mechanisms underlying the inflammation in PMR/GCA and Actremra only works on the most common one, production of the cytokine IL-6. If either or both of the other two are present, then you still need some pred as biologics only work on the one thing at which they are targeted. It has also been used in RA for some years - again, it only works for patients where IL-6 is implicated.

Methotrexate MAY help people get to a lower dose of pred or it MAY make the reduction steps easier. But there are no guarantees and it takes a year to see any significant difference in dose. The one study (out of 3) that found it could reduce the dose of pred also found at a five year follow-up that even though the pred dose was measurably lower, it hadn't changed the incidence of pred-related adverse effects. Which begs the question: Why bother? It has its own set of adverse effects.

[jinasc in reply to PMRpro]

Glad you replied and that post brought back memories of Roche etc xxx

Doing OK but tired.

[Amkoffee]

I am also in the US. I'm glad that it is working for you. I do plan to talk to my rheumatologist next week about it. My rheumatologist is a wonderful lady and is always open to trying different things. So I have little doubt that she will let me try it. But I may have to wait until I've been on mtx for a couple more months to determine if it will work.