Benefits of methotrexate (MTX) when you have OA problems in your knees

[PMRpro]

This is research from the Leeds Institute of Rheumatic and Musculoskeletal Medicine and others which found that MTX provided significant pain reduction after 6 months,

pubmed.ncbi.nlm.nih.gov/390...

Many PMR patients with OA seem to find considerable relief with pred but then become aware of the OA as they get to lower doses. Many rheumies are very keen to add MTX if they feel patients aren't progressing with their tapering as well as they would like and sometimes there is great difficulty deciding if the returning pain is due to incompletely managed PMR or OA or both.

Some patients with PMR do respond extremely well to the addition of MTX but you have to try it to find out if you are one. MTX is standard management for inflammatory arthritis and, as shown here, also potentially for OA and sometimes, we know, for PMR. Quite a few patients do develop signs of peripheral arthritis alongside and possibly part of their PMR.

If you are offered MTX and agree to trial it and find that you are one of the many who can take it without too many adverse effects, this could well be a game changer, working for 3 different conditions at the same time.

[Pixix]

can it be prescribed at GP level in England, do you know, or only by consultants, please?

[PMRpro Ambassador in reply to Pixix]

I imagine only consultants. Which is a downside.

[Pixix in reply to PMRpro]

Hm. Thought so. After my last appointment I won’t be having any more rheumy consults! As you may remember I attempted to change hospitals, but I’ve been waiting two years now (to be seen for probable inflammatory arthritis & Ehlers Danlos Syndrome). Thanks, S xx

[PMRpro Ambassador in reply to Pixix]

But who will deal with those?

[Pixix in reply to PMRpro]

Nobody…well, my GP will help me to the limit of his authorisation. Just waiting for appointment for injections…one direct for thumb, but the other one he did two years ago & it helped a lot…it’s a ‘general’ depo medrone injection…put into ??? Then ‘travels round & helps the rest (Coccydinia, sciatica, arthritis in toes & hips, bursitis in left etc). Too many places now to be able to do individual targeted…can’t remember, 3 times a year I think?! Bad ankle trouble appears to be tendons, Achilles partly, & the subluxating doesn’t help)! I’m down to 1mg, but did it too fast, at same time as scrubbing old kitchen tiles to get dirt out of pores, then 2 coats of sealant…4 days hard labour!! And, no, I will never learn! S xx

[PMRpro Ambassador in reply to Pixix]

A general depotmedrone injection is done into deep muscle - buttock mostly. And they can be done monthly - used like that to manage PMR. The 3x annually is for joints/tendons.

[Pixix in reply to PMRpro]

Yes, I recall now, it was buttock last time!! I like the idea of being able to do it more often, too. Will discuss! He doesn’t know yet that the Buphrenorphine patches aren’t working well (but that I think it became much less effective when they changed the brand used (cheaper, I guess!) ah, that’s it…3 times a year, that’s what became difficult with two thumbs & two big toes in difficulty!! Are you still in Garda, or have you gone home now…we’ve holidayed in Limine (a few times), Desenzano & Bardolino in the past, & had lovely times…but the last time it was so busy, we stayed in Garda in early October. People were queuing & not getting space on the boats & waiting hours for transport. Hope you had a great time! S xx

[PMRpro Ambassador in reply to Pixix]

No - 5 nights, 6 days as I arrived at 11am and left at 1,30, the Lazise municipal campsite is very civilised like that except you do have to turn up and wait for someone to leave, can't book! Early October is very popular with Germans, that is why it was so busy. This weekend was very busy as Friday was a public holiday in Italy and Austria, Some hotels and restaurants had already closed and so had most of the west side of the lake and some sites on the east. But it was mainly daytrippers from Verona I think. Been going to Lake Garda for over 40 years, always seemed to end up there somehow, especially once we had bought the flat here and put our caravan on a storage site there, one night in a hotel on the way down was so much better than driving all the way, But always the south eastern corner, Bardolino and south to Peschiera. Lake Ledro was nice up at the other end - totally different and much quieter.

[powerwalk in reply to Pixix]

Who came up with that was it your GP for the depo med injection? Interesting.

[Pixix in reply to powerwalk]

The injection has nothing to do with PMR, in my case. I am on 1mg now, & tapering very slowly. I suffer from Polymyalgia Rheumatica, Fibromyalgia, Raynauds Syndrome, Osteoarthritis, Hypermobility, Essential Tremor, Vertigo, Trochanteric Bursitis, Haemangioma - spinal, Asthma, Sciatica, Orthostatic Hypertension, Coccydinia, Blepharitis & macular Degeneration. My osteoarthritis has worsened to the extent that I cannot use one thumb & the other is very painful. My toes are dreadful & my ankle has been x-rayed, nothing broken, but something very wrong with it. The depo medrone is to help the rest of my issues, not the PMR, which, at 1mg is inconsequential!! I guess you thought it was interesting from the PMR/GCA point of view. I’ve needed a lot of guided injections & specific places injected over the past 4 years, none of them for PMR, & none of them helped my PMR. Sorry if you thought it was a new treatment for PMR. S x

[powerwalk in reply to Pixix]

No not PMR either. Have tons of other pain. Fibro, hip, everywhere really. Have also guided injections rhizotomy. Its a bad joke at this stage. Wondering if something like this wd help widespread pain. Thank you for getting back to me.

[PMRpro Ambassador in reply to powerwalk]

Depends what's causing it. Only if it is due to inflammation.

[powerwalk in reply to PMRpro]

Right. Thank you. Clutching at straws.

[Pixix in reply to powerwalk]

Oh, OK…sorry, I just assumed you were thinking “pmr”. I’ve found nothing that helps my fibro pain, or I’d gladly share it with you. Many people find help by taking gabapentin or Pregabalin, but I couldn’t take either. I was told a rhizotomy would last about 16 months, but then it kills nerves, so depends on what’s causing nerve pain for you. I had 4 car crashes & a nasty cycle crash, so I’ve been in pain, acute & chronic, for 14 years. At the moment I’m trialling a combination of time release Tramadol (the trade name Zydol is more effective for me than the cheap alternative I trialled), & Butec bruphrenorphine pain patches. At the moment, something hurts 24/7. If one bit stops, another starts. I have never found the Depo medrone helps with my fibro pain, sadly, but does help with osteoarthritis, Coccydinia, bursitis. Please note the word help. It doesn’t stop the pain, it eases the pain of those three diseases to better, not quite so acute!! I’ve yet to find the miracle that stops the pain. Full stop!! S x

[powerwalk in reply to Pixix]

Yes theres a lot going on for you. I know, i wish or a miracle drug, the pain is just relentless made much worse by a bad reaction to a recent bone med infusion. We can only keep trying. Thank you.

[Pixix in reply to powerwalk]

Keep trying, & don’t give up. I have waves of giving up, or wanting to…but then just keep going!

[redruth123]

Thank you so much for posting this.

[Bcol]

That's very interesting, thank you.

[bright-horizon]

This is very interesting and I'll share it with my GP next visit.

I've been on MTX from the outset of GCA (Nearly 6 years ago) prescribed by the rheumatologist as a steroid sparing med. Since I am still on the prednisone after a few flares and dosage bump ups I'm not convinced about the 'sparing' . But I do have OA in both knees which I'm managing with exercises and a bit of Capsaicin cream. I guess it's possible the pain would be greater without the MTX. Since it hasn't created any unpleasant side effects I'll stick with it and see if I can avoid knee surgery.

My hip OA accelerated drastically after 4 years on prednisone and when I finally had a total hip replacement this year the surgeon discovered I had osteonecrosis of the femur head and severely atrophied hip muscles. That has meant a very slow recovery from surgery and after 7 months I still cannot walk unaided for more than a few steps.

Not sure if MTX therapy is connected to all this, but I'm boxing on. At my grand age of 82 I want to avoid another orthopaedic surgery !

[PMRpro Ambassador in reply to bright-horizon]

It is rare, but pred can underlie osteonecrosis. This is why even if hip OA is known about, sudden deterioration in symptoms should trigger investigation.

[bright-horizon in reply to PMRpro]

I know that now but strangely when I reported the deterioration to my gp he tried me on stronger pain meds (didn't help) and requested I be put in a more urgent category for the hip surgery wait list. No consideration of investigation or imaging. The surgeon had no idea until she opened me up - severe osteonecrosis plus the gluteus medius detached and shrunk right back. It all bothers me now, considering my rehabilitation is very slow and the hip still hurts. When I saw her in September she said it's all going as expected, the discomfort and 'clunking' in my hip is nothing to worry about. She doesn't want to see me again until the new year to consider going the list for one of the other 3 joints with OA. I fear the same might happen to my other hip, with another long wait in our underfunded NZ hospital service.

My strategy is to insist on investigation if there is any sign of a sudden change, and not accept a 'let's wait and see' approach. Meanwhile I persist with my rehab exercises, and hope the other hip doesn't develop the same problem, which is known to happen.

Sorry to go on...it's probably a displacement rant after the woeful outcome of the US election!

[PMRpro Ambassador in reply to bright-horizon]

Don't - just wondering how long it will be before I can watch even the local news without the remote in my hand!!! We don't usually get too much but ...

I really don't understand why GPs are so averse to ordering an x-ray - one nearly killed my husband as a result. Persistent cough - 3 lots of abx that didn't work, poor peak flow so assumed it was asthma. No - a massive tumour which was found when a colleague sent him to the hospital x-ray dept. The GP had access to a walk-in centre unit open every day and practically on his way to work!! My rheumy here sends me for an x-ray any time there is an increase in pain.

[bright-horizon in reply to PMRpro]

Maybe I need to see the rheumy for help with this. Most of us must rely on our doctors to recognise alarm signals. Thank goodness for you and this forum!

Yours with remote in hand. I'm having a PMR/fibro today which I attribute to yesterday's tragedy. Ah well, back to work.

[Heron82]

Mtx has certainly made a difference to the OA pain in my wrists. Hasn’t really helped with tapering. I inject weekly and tolerate it extremely well.

Good finds on the lit searches today. Well done and hope all is well with you.

[HelenDaisy]

I am on Leflonamide rather than methotrexate as I’d had high liver function results, and it’s kinder on the liver. It has helped me taper ( I have had a couple of flares at lower doses of prednisone), but also when I suddenly had inflammatory RA in my hands, it really helped. The dose was doubled at this point.

[PMRpro Ambassador in reply to HelenDaisy]

It is an RA drug. But the point of my post was that MTX potentially has a triple effect in PMR patients with OA and it was MTX they looked at.

[PMRCanada]

Thank you SO much for posting this! I’ll be sharing it with my GP and Rheumatologist.

I am this patient exactly! OA both knees prior to being diagnosed with PMR and starting pred. Started with a couple injections in one knee, then list 35 pounds and started pred (20mg)….bingo, all knee pain disappeared!

Fast forward 5 years stuck at 9mg of pred for almost 2 years. Started MTX, dropped pred to 5mgs but took 2 years. Some knee pain re-emerged at low pred dose, but MTX seems to help. When I held my weekly MTX injection once for 3 weeks due to infection/antibiotics…boom, return of some PMR symptoms, but also sore hands and knees. So it’s obviously doing something.

Started a new job 2 months ago, had to up pred to 6mg to deal with stress, getting up earlier and less overall rest. The quandary is I’d like to be off MTX (as a steroid sparer), if I don’t plan to continue tapering lower while I’m working, but with this info, perhaps it would be best to stay on it (maybe at a lower dose, currently at 15mg MTX)?? Would hate to rock the boat with my medications now that I’m settled in at work.

Got X-rays of both knees last week…it had been 2 years and last time was told my OA was moderate. Hard to really know when the pain is masked somewhat. Will be discussing the results with my GP next Tuesday and that may help determine “next steps” (lol).

[PMRpro Ambassador in reply to PMRCanada]

15mg isn't a high dose but I suppose it might be interesting to reduce slowly and see where the symptoms return - the PMR was obviously still around when you had to stop it before. If you can have good QOL with low doses of both - makes it worth taking them doesn't it?

[PMRCanada]

Interesting the mention of University of Western Ontario (in London only 40 minutes away, where my Rheumatologist studied), AND McMaster University (an hour away in Hamilton, where my husband is from) and the related “Osteoarthritis Index stiffness measures.”

And of course the noted positive outcomes!