Start Methotrexate with Prednisone right away or wait?

Hopefully you’ll hear from others, but it sounds unusual to start with methotrexate at the beginning. I’ve not heard that recommendation before, but that doesn’t mean it doesn’t happen or wouldn’t work. In my father’s case, that did not come up until months into his taper because his care team considered if it might be best for him to taper off prednisone more quickly.

My hesitation would be that both medications are strong and frequently have side effects, even in the best-case scenario, so to take them together could be unnecessarily challenging. But in my dad’s case, he is extremely sensitive to medication, so we decided not to rock the boat and were able to continue the prednisone taper.

I did not start the methotrexate until 2 years into the disease, when I had tapered from 20 to 8mg. My doctor had wanted me to start it earlier, when I had one flare-up after another trying to get below 8 mg. I had very significant side effects with the methotrexate when I started it. I would not have wanted to deal with that at the beginning on top of prednisone side effects. Methotrexate (10 mg) allowed me to drop pretty easily down to 5 mg prednisone where I am now stuck. If I were to do it over, I would probably have started the MTX sooner, but not at the beginning. I would get as low as possible on just prednisone then consider other treatments.

Thanks Linda. My gut said wait a bit. So I will discuss more with NP. Appreciate it.

Thank you emo-

Hi, i have been on Prednisone for 7 months, was reducing from 22mg without flares. I got to 7.5mg Prednisone and was started on Methotrexate 10mg. It hit me like a ton of bricks on the 3rd weekly dose and i have had bad flares of the PMR over the last 7 weeks while taking it. It takes 6-12 weeks to have a therapeutic effect. The side effects of the methotrexate for me are mild nausea extreme fatigue and brain fog in the 24 to 48hrs after taking it. The folic acid supplement doesnt seem to help. Im going to persevere for the 12 weeks but if thigs dont improve i wont keep taking it. My Rheumatologist wanted me to start at 20mg but im quite sure i could not have tolerated it at that dose. She wasnt optimistic about Methotrexate but i had to trial it for 6mths to have access to the IL-6 inhibitor (Actemra) under our Pharmaceutical Benefits Scheme.

Ugh, I hate the whole "failing up" notion with medications... Will you still be able to try Actemra if it turns out you can't tolerate the methotrexate? Good idea to try starting at a smaller dose first to test it out.

Thank you for sharing your experience, and I hope the side effects get better or that you'll be able to switch to something more effective soon.

Hi mtr-
I am sorry you have been going through this. Thanks for the note. My dr. wants to start me on 6pills a week of the Methotrexate, so I think that is more reasonable but I hear 10 is the starting norm. Thanks to you and all for comments/thoughts. it helps.

I know what you mean, you have to demonstrate that you are 'failing to progress' on the cheap and nasty drug before you get access to the expensive (almost as nasty) more effective drug. Its just wrong on many levels. As for getting access to Actemra, it seems so far off at the moment that im just taking one day at a time, trying not to let this disease drag me into a deep dark hole...i wake up and start asking myself "what can i be thankful for..i can still cook occasionally, i can still do a bit of craft with the grandkids, i can manage a bit of light cleaning with lots of rest breaks" not totally useless yet !!!!

I had moderate or worse nausea, headaches and extreme fatigue for about 2 days after taking the methotrexate. I wanted to quit but I really needed to give it a good try since the 8 mg prednisone I was stuck on for a year and a half is too high. My labs were good and I did not have significant side effects from the prednisone. I had just been on it too long and the doctor said my body would show damage eventually. It really surprised me when the methotrexate side effects pretty much went away after a month or 6 weeks! I do have fatigue but am not sure if that is from the disease or the drugs. I have had 1 PMR flare-up in 6 months on the MTX.

Thank you so much for that Ray of hope, I needed to hear that today !!!