PREDNISOLONE and Methotrexate

[JojoBorder]

hi, I’ve been on Pred for 15 months, gradually withdrawing. I got down to 3 mg and no further - a huge flair up. My rheumatologist has now suggested I take Methotrexate 20mg once a week, as well as increase Prednisolone to 10mg. Is anyone else on both these meds at the same time ? Has the Methotrexate alone worked for anyone. Thanks

[DorsetLady PMRGCAuk volunteer]

Many are on both…. but usually because they are having issues at much higher doses of Pred.

I’d be addressing the flare initially-see this link -

healthunlocked.com/pmrgcauk...

- and then drop back to 4mg - as 3mg is obviously just below YOUR dose for now… won’t always be, but to have to got below 5mg within 15 months is very good. .. and your Rheumy should realise that… unless he’s one of the ‘PMR only last 2 years’ brigade.

Don’t see the point in adding in MTX at such a low dose…

..and use a slower tapering plan for Pred once you are back on track -

healthunlocked.com/pmrgcauk...

[PMRpro Ambassador]

Like DL, I would first address the flare and go back to 4 or 5mg - you aren't tapering relentlessly to zero but looking for the lowest effective dose. You do that by tapering VERY slowly until the symptoms reappear and then you go back to the last dose you were good at. You give it a couple of months and try a SMALL reduction - if it works, great, if it doesn't, you wait another month or two and try again. Eventually it will work.

To have got to 5mg in 15 months suggests to me you were spending at most 1 month on a new dose and once you are below 5mg you really need longer and to reduce only 1/2mg at a time.

If you got to 5mg or less on your own and are doing fine - then good rheumies would agree it is a bit silly to want to add in a drug like MTX claiming it will get you off pred. It MIGHT - but it might not and comes with its own adverse effects which can be at best unpleasant and at worse quite upsetting. It made me feel worse than PMR without any medication ever did. The fatigue was so bad I couldn't function. Others find they get every infection going because their immune system is so suppressed. And that isn't good either.

If you were stuck above 10mg, I wouldn't be saying this. You aren't - you don't need MTX at present.

[PMRrunner]

I am on both prednisolone(currently 3mg) and methotrexate (10mg) and have been on a steroid sparer for over 3 years, at first leflunomide now methotrexate. I was struggling getting below 12mg of pred when I was first put on leflunomide. Methotrexate can take a number of months to have an effect so I would try increasing the prednisolone for the flare and then reduce very slowly.I can cope with 10mg methotrexate but at 20mg like PMRpro the fatigue was affecting my daily life.

[SnazzyD]

I’d say PMRrunner sounds more like the classic case for adding in a steroid sparer. 15 months isn’t long but there are rheumys who think PMR lasts for only 2 years.

[Ozziedays]

I flared at 5mg on my first taper and my rheumatologist put me back up to 7mg plus slowed down my tapering plan.

When it happened a second time she recommended the same strategy (back up to 7mg and slowing down the taper a bit more) plus starting methotrexate 20mg once weekly. That was in October 2021.

I got to zero pred in November 2022 with no further flares. I continued with the methotrexate as per her recommendations, and those of a new GP and rheumatologist (I moved from Australia to the UK during this time) reducing to 15mg per week about 6 months after reaching zero pred, and then 10mg, and ceased in November 2023.

Whether the methotrexate was instrumental in getting me off prednisolone is of course unknown, perhaps I would have succeeded in my next tapering attempt, perhaps the PMR had just burnt itself out. It didn’t cause me any side effects that I noticed.

[JojoBorder in reply to Ozziedays]

Many thanks. That’s reassuring.

[Zampalion]

I recovered from PMR after 5years 3 years taking MTX also because of arthritis did not have any side effects came of gradually down by one tablet every two months

[PMRCanada]

I started on MTX when I got stuck in my pred tapering at 9mg. I attempted to lower down to 8.5mg 5 times in a year and a half with no success.

I’m now down to 5.5mg pred daily and MTX 15mg weekly injections. It’s been a slow go tapering pred on MTX, in part because I am further immunocompromised on both medications which resulted in me getting sick easier, and if it was an infection, I had to stop the MTX while on antibiotics. This caused me to lower my MTX dose and it has been better. I’ve never had any side effects from the MTX.

As others have mentioned a “pred burst” will likely address your PMR flare so no need to go back up to 10mg pred, and if you settle back at 4 or 5mg pred, I wouldn’t bother on-boarding MTX….it’s considered a low dose. Remember….”the lower, the slower” when it comes to tapering. I’d be thrilled to get down to 5mg pred in 15 months….it’s taken me over 5 years to get where I’m at currently.

[JojoBorder in reply to PMRCanada]

Thanks for that. What do you mean by ‘on-boarding MTX’.

I wish you well in your recovery.

[PMRCanada in reply to JojoBorder]

It’s just a term I use meaning to start taking a new medication.