bombing a flare

[papadapadoo]

When excruciating sciatica sent me to the emergency room several years ago, I was administered 20mg of dexamethasone (Decadron) to cut the rampant inflammation, which provided relief within an hour. That was followed by a Medrol pack for the next week and, with exercise, I got over the sciatica. Of course, we know about sciatica but not about PMR, and they are so very different in kind and effect. But my question is this: in the case of a PMR flare, might it be effective to hit it with a larger dose of prednisone (say 60 mg if we had tapered to 8) to clear out the accumulated inflammation, and then return to where we were PLUS one mg for a short time? I can't find any science on this, but the experienced leaders on this board may have some thoughts.

[DorsetLady PMRGCAuk volunteer]

That’s a bit OTT.

Usual advice we give is contained within this post -

healthunlocked.com/pmrgcauk...

..and most guidelines say similar to this -

We recommend the following approach to relapse of disease.

Relapse is the recurrence of symptoms of PMR or onset of GCA, and not just unexplained raised ESR or CRP

Treatment of relapse:

Clinical features of GCA: treat as GCA (usually oral prednisolone 40–60 mg daily) (see GCA guideline)

Clinical features of PMR: increase prednisolone to previous higher dose.

Single i.m. injection of methylprednisolone (depomedrone) 120 mg can also be used.

Further relapses: consider introducing DMARD therapy after two relapses

[papadapadoo in reply to DorsetLady]

"Single i.m. injection of methylprednisolone (depomedrone) 120 mg can also be used." So yes, I guess you could bomb it. But in the light of the long-term features of the disease, that's probably not the right way to go, since we're not in a hurry. Thanks, DorsetLady.

[DorsetLady PMRGCAuk volunteer in reply to papadapadoo]

Not sure what 120mg depomedrone equates to in oral Pred dose but as the subject is a PMR I doubt it’s 60mg. But I do know someone who will.

[PMRpro Ambassador in reply to DorsetLady]

See my reply quoting Admiral06's experiences.

[DorsetLady PMRGCAuk volunteer in reply to PMRpro]

thanks…

[piglette]

It is rather like saying why not use a whole pack of weedkiller to kill a single weed. Yes it would work, but you would be wasting an awful lot of weedkiller. Same for steroids, just use what you need.

[PMRpro Ambassador]

I would say that is total overkill. It might work a bit faster but that is a massive dose of pred and we think it is better taking a smaller amount extra for a week or so - and that almost always works if the problem was overshooting the dose you need, In the case of an increase in disease activity you might need a reset of the dose but for PMR 60mg is still far too much - they don't use that much at the start so why use it for a flare.

The i.m. dose of depotmedrone is not a one-off bomb, it releases slowly over a period of 3 to 4 weeks, more at the start and naturally tapering over time. It is different when used as a deep i.m. injection than it is for a joint injection.

There are explanations of how it works in the posts Admiral06 put up about his experiences with depotmedrone, including research on the dose-curve.

healthunlocked.com/user/Adm...

[papadapadoo in reply to PMRpro]

Very interesting! Thank you.

[Pixix]

I had a depo medrone injection about 7 weeks ago. It was for a completely different reason & not intending to help my PMR. It gave me a new lease of life for 3 weeks, & did help the PMR, I think. But after 4 weeks everything returned to normal. PMR just the same afterwards as before! It was a good diagnostic test for the other disease & proved my doctor is a good diagnostician! But you can’t have them every month, I think 3 in a year, maybe. So not of any use in an illness known to last 2 - 5 years, & more in many cases, I would think. Hope this helps…

[PMRpro Ambassador in reply to Pixix]

"you can’t have them every month, I think 3 in a year, maybe"

Yes you can. The injections used for PMR - and it is an approved approach - are deep i.m. and then work as a slow release over weeks. The sort that should be restricted are the INTRAARTICULAR form for joint problems or for tendonitis.

Prof Dasgupta did the first study back in the early 1990s:

ncbi.nlm.nih.gov/pmc/articl...

and they were mentioned in the 2015 Recommendations for the management of PMR.

There are doctors who claim to specialise in PMR who don't know the difference - it does annoy me that misinformation continues to be disseminated by people who should know better.

[Pixix in reply to PMRpro]

ah, OK, I’m sorry I didn’t know better. I started having them five years ago, for osteoarthritis, & usually had 4 a year. Yesterdays injection was for bursitis. Dr wanted to wait until some weeks had passed since the depo medrone. I was just speaking from experience. I probably shouldn’t have commented as my treatment wasn’t for PMR.

[PMRpro Ambassador in reply to Pixix]

But the point is - you CAN have them more than 3x a year if they are deep i,m, shots - in your bum usually. If they are more superficial as bursitis ones often are, maybe less often, not sure about that.

[Pixix in reply to PMRpro]

They are banned by my consultant now, sadly! Yes, depo medrone was in the bum…bursitis direct into problem area, but more superficial.