I saw a new Rhematologist today for a second opinion on whether I really have PMR and if so is my treatment correct. My current Rhematologist started me on 20 mg of prednisone and over the has lowered the dose to 10 over the last 3 months. She wants to go from 10 to 7.5. Based upon what I’ve learned here that seemed aggressive and I told her I will only reduce by 10%. She very reluctantly agreed.
The md I saw today agreed with me about 10% but also wants to start me on methotrexate injections while slowly reducing the prednisone until he can get it down to 4mg.
Does this seem like a reasonable approach to those of you with much more experience than I.
Thank you for your support/suggestions. Also, are there any special concerns I should have about Methotrexate
Jer3jen
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jer3jen
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Doesn’t sound like it, so unless you have any other health issues which are exacerbated the steroids, don’t really see the point in adding in another medication - with another set of side effects - to the mix.
Others, who are on MTX will be along idc to answer.
During his physical exam he felt sone restrictions in my shoulders which he attributes to a very minimum flare of my PMR due to Prednisone reduction from 10 to 9. He believes even slow Prednisone reduction will cause flare. He says he would have started me at PMR diagnosis with both Prednisone and Methotrexate which he claims is safe with minimal Side effects
During his physical exam he felt some restrictions in my shoulders which he attributes to a very minimum flare of my PMR due to Prednisone reduction from 10 to 9.
A reduction of 0.5mg and a slow taper - such as link (there are others) might stop any future flares.
Personally I wouldn't want to add another drug at present until I saw how I got on with reducing below 10mg on my own and using a sensible reduction approach - NOT 2.5mg at a time at this stage!! I don't have any objection to the suggestion of trying mtx if a patient has been stuck at above 10mg for a long time and struggles to get lower. You may well get to 5mg all on your own without adding in the other layer of side effects of another immunosuppressant medication, especially at present.
Yes, they have access to Covid vaccines now. But the supply is still limited and above all it isn't known how well that will work for those of us on immunosuppressant medication - the recommendation from a study is that you drop mtx for 2 weeks at least after having a vaccination. At present it is still thought that the more medications you are on that suppress the immune system, the more likely you might be to catch Covid if exposed to it.
I tried mtx but the adverse effects for me meant I stopped after a month - no nausea even with oral mtx but the fatigue was overwhelming and increasing week by week, I was already at only having 1 day feeling half-decent, the one the next dose was due before bed! It may have potentiated the pred effect on the PMR - but it was at the expense of potentiating things that are usually said to be pred side effects which appeared when I had never had them with just pred, whatever dose I had been on: hunger, weight gain, bruising, joint aches and pains. I felt worse on mtx than ever with untreated PMR!!
If you can take mtx without side effects then it may well be worth trying - not saying it isn't. But I would want to be sure I had tried without first. Expecially at present.
Starting PMR patients off with steroids, methotrexate and often a bisphosphonate, such as Alendronic Acid, seems to be the belt and braces approach of a lot of rheumies. Methotrexate has its own problems and I am averse to any drug, as I seem to react so badly to them. Some people have no problems and again some think it helps them reduce the steroid dose, others think it doesn’t! On reducing you often feel a bit achy initially due to the body missing the steroid dose, this only lasts for a couple of days or so. A flare does not seem to happen for at least a week after reducing and does not go away like the steroid withdrawal.
Why start another immunosuppressant when you are not proven to be ‘failing’ to reduce and it isn’t as if you are stuck, just that you might need to be slower. Besides, once below 8mg your adrenal glands may be slow to make up the difference and Methotrexate won’t help you if that is the case, only a slow taper.
My hospital Rheumatologist ( not private one) mentioned mtx , as a means of speeding reductions, sees me as behind curve for GCA reductions per NICE I.e. on dose after 4 months when NICE suggests dose after 3 months. Also said instead of staying on a dose for 2 weeks could reduce this to 10 days, I declined! He is hell bent on a rapid reduction. I also declined the mtx as reductions have been proceeding well apart from initial hiccup around 50/60 mg, and I do not want to add another drug and it’s side effects into the mix.
P.S from my notes of telephone conversation aim for GCA is to get to 15/20 mg dose in 3 months
Needs to read all the medical literature about tapering - every single one says that the tapering regimen must be adjusted and tailored to the individual patient. There is not a fixed in stone timeline - and anyone who tries to impose one runs the risk of getting into trouble.
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