Can prednisone be administered concurrently with methotrexate (MTX)?

From the Guidelines

Yes, prednisone can be administered concurrently with methotrexate (MTX), as evidenced by a recent study published in the Journal of Crohn's and Colitis in 2024 1.

Key Points to Consider

• The study found that parenteral methotrexate monotherapy can be used as maintenance therapy in moderate-to-severe Crohn's disease, with a significant proportion of patients achieving clinical remission when treated with methotrexate and concomitant prednisone 1.
• The combination of methotrexate and prednisone has been shown to be effective in inducing and maintaining remission in patients with Crohn's disease, with a significant reduction in steroid use 1.
• However, the use of methotrexate and prednisone together requires careful monitoring for side effects, including increased risk of infection, bone density loss, and liver function abnormalities 1.
• Regular blood tests to monitor complete blood count, liver function, and kidney function are essential when using these medications together 1.
• Patients should also take folic acid supplements (typically 1 mg daily) when on methotrexate to reduce side effects, and should avoid alcohol consumption due to increased risk of liver toxicity 1.

Important Considerations

• The effect size estimates for remission are imprecise, and the results may be confounded by the concomitant use of corticosteroids 1.
• The rate of treatment discontinuation for adverse events was significantly higher when compared with placebo, mainly due to elevated liver enzymes and nausea 1.
• Methotrexate may be considered as an option for steroid-dependent patients when alternative options, including surgery, cannot be used, and the teratogenicity of the drug must be considered and patients counselled appropriately 1.

From the Research

Administration of Prednisone with Methotrexate

• The administration of prednisone concurrently with methotrexate (MTX) has been studied in various contexts, including rheumatoid arthritis, sarcoidosis, and polymyalgia rheumatica 2, 3, 4, 5, 6.
• A study published in 2023 found that the addition of low-moderate dose prednisone to MTX treatment can alleviate common MTX side-effects in rheumatoid arthritis patients, specifically nausea and elevated ALT/AST 2.
• Another study from 2013 evaluated the clinical efficacy and safety of MTX plus low dose glucocorticoid in the treatment of rheumatoid arthritis, and found that this combination was effective and well-tolerated 5.
• A 2004 randomized, double-blind, placebo-controlled trial compared the efficacy and safety of prednisone plus methotrexate and prednisone alone in patients with polymyalgia rheumatica, and found that the combination of prednisone and methotrexate was associated with shorter prednisone treatment and steroid sparing 6.
• A 1999 study examined the use of MTX and daily prednisone as the initial treatment of Wegener's granulomatosis, and found that this combination was effective in controlling the disease, although chronic disease courses were common and the likelihood of disease relapse was high 4.
• A 2021 study evaluated patient-reported side-effects of prednisone and methotrexate in a sarcoidosis population, and found that methotrexate seemed to have fewer and less bothersome side-effects than prednisone 3.

Key Findings

• The concurrent administration of prednisone and MTX can be effective in reducing MTX side-effects and improving treatment outcomes in various diseases 2, 5, 6.
• The combination of prednisone and MTX may be associated with a lower risk of adverse events compared to MTX monotherapy 2, 5.
• The use of low-dose prednisone in combination with MTX may be a useful therapeutic strategy in patients with rheumatoid arthritis and other diseases 2, 5, 6.