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Love me, love me not

This is a message that I have wanted to spread for a long time. I want to start with a quote of one my training mentors used to say, Dr. Ali Askari, "Serious conditions require serious treatments."


Rheumatoid Arthritis, It is an illness that I take very seriously and it is our duty as rheumatologists to educate our patients regarding treatments, side effects and why there is a need to prescribe this medications which most of time it is a long term treatment.


I need to do always better and accept that I have a responsibility to educate my patients and the people around them, both medical and social.


Methotrexate is a very useful medication. Rheumatologists would all agree. We use it for rheumatoid arthritis and many other types of autoimmune conditions.


I’m comfortable with it and have hundreds of patients on this medication. Everyday, I spend a proportion of my time looking at Methotrexate-monitoring blood tests for patients using this medication. Every week, I would write a number of prescriptions.

It’s also true that I would regularly spend a lot of time allaying patient fears about this drug.


Why?


Bad press. And misinformation. Lots of it. Perhaps too much google.

Methotrexate has been used as chemotherapy at much, much higher doses and in different formulations than those used in arthritis. This leaves it with a stain. A little knowledge is a dangerous thing and many friends, family members, well-wishing members of the community, and even, some health professionals are guilty of scaremongering.


When rheumatologists use Methotrexate in the context of arthritis, it is NOT chemotherapy. It’s an arthritis drug.

In fact, the doses we use, which are much lower, with the medication used once weekly only, and orally in the majority, are typically well-tolerated.

I am not saying that Methotrexate should not be used with caution or that it’s side-effect free.

Every medication has POTENTIAL side effects. As doctors. we would prescribe a medication if the potential benefits of the medication outweigh the potential risks of that medication. We also monitor the patient’s clinical state as well as blood tests closely to ensure safety. Side effects if they develop can be dealt with quickly and if necessary, the dose is reduced or the medication ceased. All it takes is good communication between patient and rheumatologist.

I write this post because of the many patients who are dissuaded from taking Methotrexate due to some scary thing they’ve read or been told about.


Typically, if your rheumatologist has suggested Methotrexate, there’s a good reason. In the case of rheumatoid arthritis, it’s because rheumatoid arthritis is a serious disease with many bad consequences when it’s not treated adequately. Methotrexate is the initial, go-to drug in most cases.


So, why do I use Methotrexate as my 1st line treatment for Rheumatoid Arthritis (RA)?

  1. Familiarity. MTX has been used for over 30 years in RA. We're comfortable with it. There are few surprises.

  2. It works. When used at an early stage & at adequate doses, and those are important points, it is effective in RA. Remission rates have been reported around the 40% mark and this would be consistent with what I experience.

  3. It's good in COMBO. There are numerous trials showing additional effect when Methotrexate is used in combination with biologic therapy and other DMARDs, such as Hydroxychloroquine, Leflunomide, Sulphasalazine, and many of the biologic DMARDs including the TNF-inhibitors.

  4. It's cheap (but not nasty).

  5. It's convenient. At least, in oral formulation. My standard dose is 20mg once a week which translates to 2 tablets once a week only.

  6. It's required. As part of the qualification process for using biologic DMARDs in many countries, including Australia. Due to the points above, most regulatory bodies mandate that only patients who do not respond adequately to or who cannot tolerate MTX, can access the very much more expensive biologic DMARDs.

Methotrexate does not work for all. This is true for many. Rheumatoid arthritis management must be flexible, with regular patient follow-up, and treatment change & escalation as required. There are now many options with lots more on the horizon.


Methotrexate isn't the perfect drug but it's the current 1st line treatment for the reasons above. I hope this discussion helps you understand why.As always, I invite your thoughts. This discussion is important and I'm happy to facilitate it.

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