PMR and Methotrexate

RheumNow experts online stated that it takes 6 months for MTX to begin helping, and there is little proof that it's effective in PMR.

I listen on YouTube to some top rheums talking about PMR, which they rarely do. One lately, a real pro, said that he recommended splitting the dose, even though many believe it's best not to. I could not get through the night on 20mg and would have had to increase it. Splitting the dose made all the difference, still splitting on 3.5 mg.

I was diagnosed with PMR about 15 months ago. My first assigned prednisone dosage was too low, so my rheumatologist increased it to 30 mg daily (which I split at breakfast and dinner), with a more gradual taper. I was fine until around 3 mg daily, when inflammation returned. At that point (last February), he started me on methotrexate 15 mg weekly (7.5 in am, 7.5 in pm, Saturdays only) and 1 mg daily of folic acid (for possible methotrexate side effects), with 15 mg daily prednisone (7.5/7.5), with a slower taper when I got to 5 mg. I'm currently on Day 6 without prednisone and I feel fine so far (no pain), but I'm still on the same weekly dosage of methotrexate and daily dosage of folic acid for now. My next rheumatologist appointment in in about a month, so I think I'm due bloodwork then, which may indicate whether I need methotrexate anymore, but I'm not sure.

To summarize, methotrexate seems to have worked as far as getting me off prednisone without inflammation returning, for now. No bad experiences yet, all positive so far.

Great job. 15 months is pretty good for most. I did not take an immunosuppressant but I can say that it took about 3 months to feel like my bodies cortisol production was back to normal. So I would think you should be able to stop methotrexate. I just wouldnt do it to quickly. Give your body time to completely adjust.

Yea mine spiked on Prednisone but not the other drugs ive been on

As I've mentioned many times before on this forum, early in my journey my Rheumatologist was of the opinion that my inflammation was in the severe range and I would probably not get off Prednisone. She put me on Methotrexate but I couldn't tolerate it. She wanted me to take Leflunomide but I was very reluctant. I agreed to take low dose Plaquinil because it had fewer side effects. Now, 12 mths later, I'm on 3.5mg Prednisone, 300mg Plaquinil and haven't had a bad flare for over 6 mths. I split my dose fairly early in this journey and still split it. Life is not pain free but inflammation is under control and function is good. My research leads me to believe that I probably have a (fairly common) genetic polymorphism that doesn't allow me to properly metabolise some drugs. If I had taken the very strong immunosuppressive medication my Rheumatologist wanted me to take, I am likely to have been much sicker for a lot longer !!! These drugs work well for some people with few side effects, for others it can be a big mistake. The technology for being able to tailor drug therapies to individuals is nearly there but it will take the medical establishment another 10 years to catch up. Meanwhile we need to trust our gut and do the research.

I'm 75 y.o. male with pmr for 3 years with multiple relapses and dose increases. Started mtx 3 months ago at 10mg weekly then increased to 15mg weekly for last 2 months. Was on 7.5 mg of prednisone and got down to 4.5 after the 3 months. Pmr symptoms returned and crp elevated more each month. Rheumatologist said just stop mtx and increase prednisone to 10 mg. This worked but wondering if anyone else found no results from mtx?

I have seen lots of posts where MTX did not work. Its an RA drug being used to treat inflammation. RA drugs are a lot more plentiful. There are newer biologics that target the IL-6 receptor. They have shown IL-6 to be elevated in PMR patients. Actemra is designed to treat GCA as well. Kevzara is the PMR drug. I have also seen where these drugs including MTX can take 8 to 12 weeks to start working. But keep in mind all these inflammation drugs are designed to keep your CRP down while trying to taper. They do nothing for restarting your cortisol. Below about 5mg of prednisone is going to still require a very slow taper and restarting your adrenal glands.

Thanks for your response.

In my opinion, prednisone perpetuates PMR after the adrenals are suppressed. I wonder how many people understand this or am I the only crazy person?

PMR is basically a condition of unregulated inflammation. A normal amount of cortisol isn't enough to get the inflammation under control. It isn't a shortage of cortisol though. The problem seems to be an excess of the IL-6 cytokine.

When we take higher doses of prednisone it replaces cortisol. We feel better because the inflammation is regulated by prednisone. However, when we attempt to taper off prednisone, we are confronted with prednisone induced adrenal insufficiency and a low cortisol level.

Adrenal insufficiency is an entirely new condition that mimics PMR. The treatment for adrenal insufficiency is to take more prednisone. We believe it is a PMR flare instead of adrenal insufficiency pain because of the response to more prednisone

This is the only way I can explain how Actemra worked so well for me. It is my belief that Actemra targeted the problem of excess levels of IL-6 and didn't suppress my adrenal function. After my cortisol level normalized, I could stop taking prednisone.

Now PMR is under control because the-pro inflammatory effects of L-6 are blocked. I don't need prednisone anymore.
https://www.sciencedirect.com/science/article/pii/S1043466621003318#:~:text=IL%2D6%20plays%20a%20major,%2D1%20and%20TNF%2D%CE%B1.
PMR is still treated as long as I continue to take Actemra. I don't know if and when I will be able to stop Actemra. My rheumatologist has never said I was "cured." About all that is said is that I'm "better" being off Prednisone.