Prednisone and Methotrexate questions

Well, your Rheumatologist wants you to reduce by 2.5mg every 3 weeks, but does the PMR want this?  Very probably not as these are huge jumps and I can't say I am surprised that you have pain returning. If you need 15mg to control it right now, then that is what you need, whatever the rheumy says.  S/he hasn't got it, you have.

I was on methotrexate for 2 years.  It took 10-11 weeks to work and then it's usefulness became limited, in the end it simply didn't work, so was stopped. I was offered an alternative medication, but I decided that enough was enough, so declined.  I didn't feel that I was missing anything.

Methotrexate does work for others, so you may find it does help you to reduce the steroid dose.

I started my prednisone in September at 20 mg and right now I am just at 12 mg. That is because I keep going up and down and up and down because my rheumatologist keeps pushing me to taper faster than my body can handle. I finally had to put my foot down at my last appointment and so now I'm tapering at what my body can handle. So far so good. I'm hoping it goes well for me. I would suggest that you stay strong with your rheumatologist and insist that you slow down your taper considerably.

There is no evidence to show that methotrexate makes a significant difference in the long run. If what you have is PMR then it won't replace the pred, at best it may allow you to manage on a lower dose of pred but it doesn't happen for everyone, It does for some.

An Italian follow-up study published a few years ago showed that, while the original study had shown patients had been able to reduce their pred dose, in the follow-up it was found that the patients had suffered exactly the same level of pred-related adverse events whether they had been on mtx or not and that some 30% of patients still required some pred after 6 years. All the mtx did was add another layer of potential side effects. If mtx was so good they would use it more - they don't and the most recent recommendations say it should te tried in agreement with the patient, nothing more.

Your rheumy doesn't appear to have a clear understanding of how PMR and tapering works. You are never reducing relentlessly to zero - you are looking for the lowest dose that manages the symptoms as well as the original starting dose did, that is your reference. And that is all pred does, it manages the symptoms to allow a decent quality of life in the meantime until the underlying autoimmune cause of the symptoms burns out and goes into remission. If you have a return of symptoms you are already dicing with the lowest dose for now - it doesn't mean you won't get lower, just not yet. You may be just 1/2mg lower than what you need - the body sheds a new dose of inflammatory substances every morning and what you are looking for is the dose that is enough to combat that each day. If the dose is slightly too low the bucket of inflammation will refill as if there were a dripping tap and symptoms will reappear. 

The problem with reducing with such a large drop and so often means you may miss the right dose and then have dropped again before the symptoms resurface. No drop in a taper should be more than 10% of the current dose to reduce the discomfort of steroid withdrawal  - which is so similar to the original disease that you can't tell whether it is a flare or withdrawal. Maybe you need 15mg, but maybe you need 13mg, and here is a big difference.

In this link you will find a lot of links to good information - including the recommendations I mentioned. In the replies section you will find a slow reduction methods that has worked wel for many patients - without mtx.

https://patient.info/forums/discuss/pmr-gca-website-addresses-and-resources-35316

In the meantime, I wouldn't reduce any further or you may have a real flare. I would slow down the speed at which you reduce and do it in 1mg steps if possible. It maybe that just alternating 15 and 12.5mg is enough to remove those niggles - but the swinging about of dose is hard on the body. And going to alower dose, developing a flare, going back to a higher dose to manage it may work once but the more often you do it the riskier the yoyo pattern becomes.

Roslyn, you now have all that you need to know.  Let me add a few comments.  First of all, I am surprised your Rheumy would add Methotrexate to the mix so shortly after your having been diagnosed.  We read on about all kinds of drug cocktails being prescribed as additions to Prednisone, but generally only after a long while and often from prescription-happy doctors. 

I was placed on MT a year into my PMR when the inflammation migrated into my hands and wrists. My doc concluded - wrongly, I might add - that PMR doesnt affect the hands and thus I must have late onset rheumatoid arthritis (LORA).  I took MT for about two months with zero improvement.  Then I read about its laundry list of side effects - most disturbingly about liver damage - and I stopped the very next day.  You can do that with MT.

Lots of discussion on this site about a range of additional magic pills to ease the burden of PMR.  Some folks claim benefit; most do not.  The only true magic pill is prednisone, but only to relieve the pain. It cures nothing.

Finally, everyone on this site will warn you about tapering too quickly.  (In my view, you are tapering too quickly!)  As Eileen noted, your objective is not to get off prednisone.  It is to manage your disease which runs its own course and has a mind of its own.