Start Methotrexate with Prednisone right away or wait?

No need to be more immunosuppressed at the onset.
Give prednisone more time to work. If you have doubts
schedule with a rheumatologist.

I starting seeing a rheumatologist a couple of weeks after being diagnosed and started on 15 mg of prednisone by my GP. The rheumatologist has a good reputation and has been in practice for 30 years. He started me right away on methotrexate 5 pills of 2.5 mg 1 night per week along 1 pill of folic acid every night. He wants me to have labs one week before I see him at every visit. After 4 weeks my ESR was down to 9 from 121 and CPR was down to 5.5 from 65. We began titrating my prednisone from 15 to 12.5 mg for one week and this week I’ll go to 10 mg. He increased my methotrexate to 6 tabs of 2.5 mg once a week. He says we’ll go to a max of 9 tabs while very slowly titrating down from 10 mg. Prednisone depending on my labs and how I’m doing. I have been tolerating both of the medications, with some tolerable side effects, which is to be expected. I have also been doing my part by adhering to a low sodium diet, no processed foods, no sugar, drinking lots of water, getting 8 hours of sleep and walking 2 miles a day. Yes I have fatigue, occasional stiffness, aches and pains and mood swings but I feel 80-90% better than before I started on meds. I am following my doctor’s orders because I don’t feel he would continue to treat his patients with medication that he knows doesn’t work or that made them feel miserable. I have good insurance so he doesn’t have to make me fail on the “cheap stuff” before starting me on something that may be more effective. This condition and its treatment is so different for everyone. I think the lab results have a lot to do with what the doctor does with the meds. I ask lots of questions when I go see him. I’m sure there will be lots of twists and turns during my treatment of this stubborn frustrating condition, and no quick fixes, but I have to have confidence in my physician and his years of experience in treating PMR. As a 75 year old with osteopenia, I know my bones will not withstand staying on higher dosages of prednisone for long so I appreciate his urgency to get it down as soon as possible.

Elayne, I was diagnosed with PMR in Jan 23. Went to Kevzara when I was at 2.5 prednisone and came off prednisone in Jan 24 entirely. Personally I do not think going on the alternative so soon is a great idea. Nothing against your NP but how familiar with PMR is she?
Best of luck.
PS, I am off everything at this point.

Thanks for this. I have not heard of Kevzara, but it is so comforting to know you are totally off everything now! Congrats. I clearly need to circle back and ask more questions. Much appreciated.

Hi Jiffaw,
Thank you for this. I think you are right, I saw the NP and did not get enough info and don't have confidence in being prescribed meds and sent on my way. She said she would check labs after one month, then every three months, but that made me nervous. Glad to hear also how you started and felt. Thanks for insight. Great that you can walk that much, I will be glad when I can again!

I looked for studies online about methotrexate used with prednisone for PMR. Older studies seemed to say it might be useful but nothing definitive. I found a 2022 proposal for a study in the Netherlands looking at giving methotrexate along with prednisone when PMR is first diagnosed. I couldn't find the completed study but maybe it isn't published yet. I can't seem to create a link but here is the study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9012047/