Hip surgery while on prednisone and methotrexate

[arvine]

Ortho surgeon has booked me for hip replacement Feb 20 , 2025, severe groin pain andosreoarthritis in hip, ( also throughout back other joints) and as Ive posted previously have chronic pain , tapered to 4 mgs pred since april this year and started methotrexate only 2 weeks ago, been told by rheumy more apt to get infection from surgery by still being on prednisone, while ortho suggests more chance of infection being on methotrezate?? So I am rethinking optionsvand wondering if anyone out there has been in similar situation when facing this, and if have had hip surgery what outcome has been

[PMRpro Ambassador]

Since it is the surgeon who is responsible - I think I'd listen to them.

[Rose54]

Hi

[ had hip replacement in July can honestly say pain free after

I took pin relief as prescribed and never took the morphin I was sent home with as never needed it

I was on 8 mg of Steroids and the dose was never a concern.

Good Luck

[arvine in reply to Rose54]

Thank you good to know, btw did you stop pred before surgery, and do you also have pmr and osteoarthritis?

[PMRpro Ambassador in reply to arvine]

You can only stop pred before surgery if your adrenal function allows it. And for anyone on pred for years as you have been, that is going to take many months. They operate despite the pred - and provide extra during the op,

[arvine in reply to PMRpro]

Oh really ? Well have appt Jan 9 with endochronologist, may be able to get test for adrenal glands

[PMRpro Ambassador in reply to arvine]

Since youa re still on 4mg, the likelihood they are working is very low. Four mg pred is plenty to suppress production of cortisol.

[arvine in reply to PMRpro]

Oh really? Hmm so what are symptons if they arent working?

[PMRpro Ambassador in reply to arvine]

Mainly fatigue but at 4mg that is enough for the body to function so it doesn't matter quite as much if you aren't making cortisol - there is steroid to compensate. I'm pretty sure we have told you this several times before.

[arvine in reply to PMRpro]

Um no I dont recall you mentioning before, but ad I said in a previous comment, have had a lot going on, and still do, so perhaps I have forgotten, I am aware pred replaces cortisol, yes, but was asking what symptons other than fatigue would adrenal glands be responsible for, sorry if Im repeating myself, but I am in quite a bad state, emotionally and physically if you can understand thst

[PMRpro Ambassador in reply to arvine]

There is a whole lot about adrenals and adrenal insufficiency in the FAQs. They are always there, you can always check what you may have forgotten. It is difficult to say what symptoms YOU may have. Overwhelming fatigue and aches are typical. You might have diarrhoea, nausea, low blood pressure, joint pain, muscle pain, low BP, craving salty foods. But you may not, especially since you are on enough pred to compensate for the lack of cortisol.

The most helpful doctor there would be an endocrinologist.

[Holycow2 in reply to PMRpro]

I find this answer rude and I’ve seen or had answers like this and they are not very helpful in fact they have the opposite effect in putting people off asking questions

[DorsetLady PMRGCAuk volunteer in reply to Holycow2]

The person raising this post has been on the forum for a number of years, so does know their way around it, including the FAQs. So is being reminded of what they have already been told, but may have forgotten.

Had you looked at the profile, you would have realised that, rather than taken PMRpros’s reply completely out of context.

[Rose54 in reply to arvine]

I had surgery in afternoon and was told to take them as normal in the morning

I have PMR and compression fracture in spine

Don’t have osteoarthritis

[piglette]

My surgeon for my hip replacement was paranoid about steroids, a lot of surgeons seem to be. He said he would not operate until I was on zero. After some ‘discussion’ he agreed on me being on 5mg which was my current dose. As PMRPro says your rheumy has nothing to do with the operation it is up to your surgeon what happens.

[Italybound62]

as a side note. It’s very interesting what I learned last week. I saw a cardiologist for a minor concern about low heart rate. I told him I’m taking Prednisone. he strongly suggested getting off Prednisone even at a low dose which I’m on - 5 mg). He said steroids can destroy hips requiring hip replacements. Somehow the steroids halt blood flow to the hips. My goodness!

[arvine in reply to Italybound62]

Oh gosh, wow! Another side affect, Im at 4 mgs, since April, afraid to taper further with all this chronic pain, but that s scary news, first time Ive rver heard that

[arvine in reply to Italybound62]

And getting off prednisone hard even without chronic pain

[PMRpro Ambassador in reply to Italybound62]

I take it that is 5mg? What a load of rubbish and he obviously hasn't a clue about PMR. He is referring to avascular necrosis which does happen and there have been one or two people on the forum who have had it but it is very rare. If you were to get severe hip pain, make sure you get x-rays done to rule it out but it can be dealt with with a hip replacement. Getting off pred is easier said than done, especially quickly, and if you did just stop it, as he seems to think you could, then an adrenal crisis is a very real risk - and they can make you extremely ill and even kill.

Luckily my cardiologists are rather better informed!!

[Italybound62 in reply to PMRpro]

Sorry. He did not mean to stop steroids cold turkey. He meant to do whatever possible to get off steroids because they are so hard in the body. He suggested switching to the new biologics.

[PMRpro Ambassador in reply to Italybound62]

We don't know the long term effects of them yet either. And it isn't always an option. Plus they probably only get half of patients off pred entirely. Pred has been in use for 70 years - not a lot that isn't known about it. I've been on pred for 16 years - even with the biologic he seems to thing is wonderful I can't get under 7mg. And avascular necrosis is the least of my concerns ...

[arvine in reply to Italybound62]

And whst are biologics, other medication that reduces inflammation?

[Italybound62 in reply to arvine]

Kevzara is an example of a biologic for PMR.

[Chocolate41]

I had a hip replacement last April.I was in terrible pain left it too long .My hip had disintegrated

It was the best thing I had ever had done.

[KASHMIRI1]

I am waiting for back surgery and my rheumys advise was to stop methotrexate one week before and for two weeks afterwards. The hospital I am going to wont operate if you are over 4.5 mgs.

[arvine in reply to KASHMIRI1]

Over 4.5 mgs of prednisone ?

[KASHMIRI1 in reply to KASHMIRI1]

Yes that's what the pre admission nurse said. I had to be under 4.5 pred.

[oscarandchloe]

I've had two hip replacements, 7 months apart. Kept on 5mg Pred for both, surgeon perfectly happy with that, but you must tell the anaethetist who will give you extra during surgery. Absolutely no trouble with either, very little pain and can walk 4 miles now after lots of physio and exercises due to PMR wasted muscles. Good luck!

[arvine in reply to oscarandchloe]

Oh that sounds positive, can I ask how long you ve been on prednisone and what your diagnosis was ?

[oscarandchloe in reply to arvine]

GCA and PMR. Started with GCA in 2019,put on 45mg and reduced down to 4mg in 10 months. At that point P MR became apparent so back on 15mgs. This has taken nearly 4 years to get down to present 2mgs as I stayed on 5 mgs for over 2 years while having the ops and recovering. I was symptom free on 5mg and felt very good so saw no point in messing with tapering. The worst adrenal symptoms have been round about 7mgs and then getting under 5mgs which I take very, very slowly ... often going back, waiting for months until feeling safe. I have had no GCA symptoms since very first dose! Hard to sort PMR hip pain from osteoarthritis until after surgery when it's clear the PMR has actually gone now. Hope this helps, do try to keep fit before I'm and do the post op exercises religiously.

[S4ndy]

I had back surgery last year. My surgeon was happy for me to stay on my 5mg if Prednisolone but insisted I had a good talk to the anaesthetist prior to my op.

So when I saw the anaesthetist I was able to discuss all my drugs with him and he made sure I received extra steroid during and after the surgery. I did think I would need to take more but I was actually able to stay on 5mg right throughout my recovery.

Good luck with the op.

[Joseph14612]

I am scheduled for hip replacement in mid January...I am on 14 mg prednisone....surgeon not concerned about the dosage.

[Rubha]

Im very interested in your situation as I am seeing an ortho in Jan with a view to TRHR. I had left done 8 years ago....amazing. i was back swimming and walking 3 and 4 miles 6 weeks later (with 1 crutch for long walks but none for round and about). I am currently on 13.5 mg of pred .....rheumy wanted me to reduce by 5 from 15 to 10....I stuck to my guns and he was ok with it as is my GP. My query is how "low" is acceptable for Hip surgery. I'll be looking forward to your replies. Good luck.

[DorsetLady PMRGCAuk volunteer in reply to Rubha]

My query is how "low" is acceptable for Hip surgery

Answer, probably depends in your surgeon, some are quite relaxed about Pred, others are not! But guessing many would like it to be nearer 5mg than 10mg, and probably not above 10mg.

[Rubha in reply to DorsetLady]

Thanks Dorset Lady. Im.hoping (GCA and PMR permitting) to be nearer 10 by then. Im reducing slowly and slower as I get lower (a nice rhyme for us pred users)....I begin 13.5 tomorrow for 3 weeks then fingers crossed 12 for 3 weeks then by 1mg ....till 10 though as we know we fon't dictate this journey

[PMRpro Ambassador in reply to Rubha]

Ideal is to be off pred. But you need to be on enough to be able to do the rehab post op - i.e. enough to manage your PMR symptoms properly or the replacment will fail.

[Rubha in reply to PMRpro]

Thanks PMR Pro..I am.lucky to be able to exercise even now. My main draw back is my hip. Even with the PMR and GCA , once Pred was stsrted and I was settled I swim twice a week and use the gym 3 times a week with appropriate equipment for my hip OA. I realise how fortunate I am to be able to still exercise. I was a long distance runner and hill walker for many years before Hip OA .Old age is not for the faint hearted .

[PMRpro Ambassador in reply to Rubha]

Certainly isn't!!! You know my mantra? The lower the slower ...

[PMRCanada]

I would say the combo of both make for a higher possibility of infection. I am on both and was sick a whole winter (4 months) with every bug going around including lower respiratory infections, cold, flu and diverticulitis flare.

I also have OA in both knees which is being monitored, and the pain is masked by 6mg pred and I suspect helped by15mg MTX.

When I was first diagnosed with OA shortly after my PMR diagnosis and starting pred, I saw two orthopaedic surgeons who both said I had a 10% higher likelihood of infection after total knee replacement surgery being on 10mg of pred at that time.

I was also told to hold my weekly MTX dose if I had an infection and/or taking antibiotics. When I had my COVID booster I was told to hold it for two weeks afterward.

Your pred dose is low so I’d be inclined to listen to the ortho. You’ve just started the MTX (not sure why if you’ve made it down to 4mg pred), so by Feb your pred dose may be even lower, or MTX may not agree with you. I’d be tempted to slowly try to keep lowering your dose and re-assess closer to surgery date. You can hold your MTX dose after the surgery for a few weeks without any harm so that may help reduce the risk of infection.

All the best.

[arvine in reply to PMRCanada]

Thank you, well the dose of pred Im on and can only take extra strength tylenol, has not helped the chronic pain, so rheumy suggested metho, it seems to be try this, see how it works, but Inhave been very tempted to increase pred dose, but trying to hang in, seebif methtrexate gives me some relief, although he said may take 3-6 mos, rather discouraging

[arvine in reply to PMRCanada]

and also his idea is may help me taper further, but??

[Potter100]

Had my hip surgery 2 days ago & am also on 4mg prednisolone. Advised to take them as normal along with any other medication. No problems & am now trying to recover. It is excruciating but hopefull will ease with every day & be worth the pain now.

Good luck with yours.

[DorsetLady PMRGCAuk volunteer in reply to Potter100]

Pain will get better - and good luck.

[Potter100 in reply to DorsetLady]

Thank you. Had one 20 years ago but memory forgets actual pain thank goodness.

[DorsetLady PMRGCAuk volunteer in reply to Potter100]

It does..I had one in 2019.. and knee in 2018 which was more difficult..