PMR: Are there treatment alternatives to Prednisone?

Mehtotrexate is not an alternative to prednisone. It can be used for polymyalgia rheumatica as a steroid sparer. So for some people having difficulty tapering, methotrexate may help alongside prednisone. Effectiveness data of methotrexate for PMR as a steroid sparer is questionable, and there are possible side-effects .

yes that’s my understanding as well. I’d be willing to try it in low doses if it helps reduce the steroid dosage even more.

Hi everyone, This is my fourth episode of PMR 1n 10 years - groan. For my last session in 2018 I had difficulties in weaning off prednisone and the methotrexate seemed to help. I've attached a graph which shows on the X axis 'time since onset' and the Y axis shows the values. It shows that each time I tried to decrease the prednisone I had an increase in pain. The medical text "UptoDate'" has this to say about using methotrexate to help reduce prednisone "Data from randomized controlled studies on the efficacy of MTX as a glucocorticoid-sparing agent are mixed, though generally favorable results have been reported with regard to cumulative glucocorticoid doses, relapse rates, and time to discontinuation of glucocorticoid treatment [42,43]. Interpretation of a negative controlled study on the use of concurrent MTX is limited by a high dropout rate [44]. These data, however, are limited by several factors including the small number of patients studied and by the relatively low doses of MTX used (in the range of 7.5 to 10 mg/week) compared with contemporary doses (in the range of 20 to 25 mg/week). Also, no study has demonstrated an actual reduction in glucocorticoid-related adverse events in MTX-treated patients compared with patients treated with glucocorticoids alone." For my present episode, I've started again on methotrexate to hopefully reduce the total time on steroids - keeping my fingers crossed! However, the methotrexate does require monitoring and frequent blood tests. Oh, and booze not allowed 🙁 Hope this helps.

Hi @guillamocan, Welcome to Connect. I've had 2 episodes of PMR since 2007 but have been in remission since 2018. I've only used prednisone for treatment but my taper off time the second time around was 1-1/2 years vs 3-1/2 years the first time around with PMR. I attribute a lot of this to lifestyle and diet changes after my first bout with PMR. Just curious if you have made any lifestyle or diet changes to see if they might help?

Hello John and thanks for the feedback. Yes, indeed lifestyle and diet changes are so important, actually essential. I already had a healthy lifestyle but I needed to be even more vigilant with my lifestyle as it was hampered by the limitation of activity (initially) and the effects from prednisone (with weight gain). One source of excellent advice was from Kate Gilbert's book "Polymyalgia Rheumatica and Giant Cell Arteritis"

I really like your chart. I also keep a daily pain journal but I have been on MTX from the point that I was at 20 mg and I have not experienced the dramatic swings in pain other than a few that were caused by specific actions like overusing an jig, reciprocating and circular saws over a short time period which caused my shoulder to scream, but only to a pain level of 4 and which disappeared after 3 days of Tylenol and no increase in Prednisone. I inject my MTX; wonder if others do. I am at 4 mgs but my body seems to be telling me not to push lower and to stay at this level a bit longer. My journey is only 9 months long so I shouldn't complain.

The graph is simple to make with an excel spread sheet. For my graph the headings for the various columns were 1) Days since onset 2) pain (peak) levels out of 10 3) prednisone (mg taken). 4) methotrexate (mg taken). In a more recent graph, I added a "T 1/2" column which represented the time to decrease to 50% of the peak pain level. I found that the graph was very useful to share with my physicians. For this recent episode, I started at 15 mg of prednisone, but had to increase to 25 mg to control the pain. At present, I'm at 15 mg with the weaning off process and I'm at 4 months since the onset. Taking 15 mg methotrexate pills. Since the main side effect of methotrexate (for me) is fatigue and drowsiness, I switched from a morning dose to the evening - works better. Hope your journey goes well.

I am newly diagnosed with PMR. I just started 20MG of Prednisone yesterday and feeling the improvement in mobility already. However, I have a history of being unable to tolerate this drug. My Rheumatologist has prescribed 20MG for the 2 weeks, then 17.5MG for 2 weeks, then moving to 15MG and slowly tapering each month. I friend of mine has mentioned I should inquire about starting IV therapy in combination or alternatively. Has anyone had experience with this approach? I'm extremely concerned about side effects of Prednisone. Thank you for your thoughts.

Hello @mikeshell, Welcome to Connect. I think it's always a good idea to review your treatment options with your doctor or rheumatologist, especially given you mentioned having a history of not being able to tolerate prednisone. There is another discussion that you might find helpful.

Actemra (Tocilizumab) to treat PMR??: https://connect.mayoclinic.org/discussion/actemra-tocilizumab-to-treat-pmr/

@kimh, @mgrogers, @tsc and others may also have some thoughts or suggestions based on their experience with PMR.

Do you mind sharing which side effects of prednisone concern you the most?

Thank you for the information. Initially, my main concern is the effect prednisone has on my stomach and the fact that if I don't eat a substantial meal, my stomach hurts, and I'm concerned ulcers will develop. The feeling of heightened anxiety and restlessness is hard to manage. I always feel very much on edge. I also have 6 cardiovascular stents and I'm concerned prednisone will cause plague buildup and/or rigidity in my arteries. Prednisone also can reduce the effectiveness of Metoprolol (which I currently take) and I have been unable increase the dosage of Metoprolol because it causes skin rashes, etc. I know there isn't a magic bullet to fix this condition; I'm hoping to find a solution that is less intrusive to limiting my active lifestyle. Thank you very much for your thoughts or suggestions. As this is a new disease for me, I'm really trying to learn as much as I can to help me make educated choices.