Which is the worst - Prednisolone or Methatrexate?

[Prof99]

I’ve mentioned my position in reply to other’s posts, but briefly, Jan 2023 - having been convinced the MTX wasn’t making any difference, I asked to stop it but my Rheumy said no, but you can half your dose to 10mg (once a week). I was also on 1.5mg Pred with Rhuemy pushing me to reduce by .5 for the next 3 months to get off it altogether. After just 2 days on the lower dose of MTX I noticed much more pain and discomfort, after 5 weeks of this I decided to put myself up to 15mg MTX. I settled back down again and was fairly comfortable so tried a slow taper to 1.25mg Pred (knowing from previous experience a drop of .5mg would be too much). I now wake every morning in pain (lower buttocks, shoulders and neck) which does ease as I get up and move around but doesn’t go completely unless I take 2 x Cocodamol. I don’t want to be taking co-codomol daily as it causes uncomfortable constipation and I fear if taken daily, it could reduce its effectiveness, but if pain killers address the pain – then are the pains adrenals/reduction related and not PMR?

So, I can’t decide if I should I go back to 20mg MTX and try to get off Pred altogether or shall I stick at the 15mg and go back to 1.5mg Pred where I was more comfortable? Which is the worst drug out of the two of them? Will I settle down on 1.25mg Pred with 15mg MTX? Next phone Rheumy appointment isn’t until July, when he is expecting me to say I am off of Pred – I just can’t see that happening. I tried phoning the Advice Line and it said they would try to get back to me in 10 working days!!!! So, once again, the advice from fellow sufferers is sought. Is it better to be on 20mg MTX and no pred or 15mg MTX and 1.5mg Pred? Any insights?

[PMRpro Ambassador]

There are NO guarantees that MTX will get you off pred altogether - it MAY allow you to get to a LOWER dose of pred but that isn't a given either. Any rheumy who says otherwise is lying. For a small and specific cohort of PMR patients it DOES work very well and the patients get off pred - BUT some patients get off pred fairly quickly anyway,

As to which is worst - depends on the patient, I have had no problems with pred even after 14 years except for the 6 months or so I was on methyl prednisolone after moving here. No prods with prednisolone or prednisone, I just couldn't get the dose down below 10mg and latterly over 15mg. I tried MTX, it was an awful experience for me. Other people take MTX and have no problems at at all, some of them get to a much lower dose of pred,

A tiny dose of pred is not likely to cause problems even long term. I'd take 5mg and no MTX if that was my option, certainly 2mg pred and the lower dose of pred would be my choice in your place if that is the mix that feels best for your QOL.

[Prof99 in reply to PMRpro]

Thank you for your reply. I feel between a rock and a hard place!