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Do rheumatologists persist with Methotrexate too long?

Do rheumatologists persist with Methotrexate too long?

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She had rheumatoid arthritis diagnosed a number of years ago. It was great that the diagnosis was picked up early and she attended a rheumatologist quickly. 

The diagnosis was made, and explained well, and she was very agreeable to commencing Methotrexate given the claimed benefits and the rationale provided.

At the start, she tolerated it well and it seemed to be helping.

Then some nausea and some symptoms of gut upset. She was told to persevere with this and she did.

Then some “fogginess” of her thinking developed as well as an increasing sensation of feeling unwell. She reported these to her rheumatologist but was apparently told to just persevere. The dose of folic acid was increased and she was asked to change the timing of her Methotrexate.

She recalls being told to take Methotrexate on the weekend so that the side effects wouldn’t affect her work day!

After one year, she had enough.

Methotrexate was stopped. Rheumatology review was not attended. She felt she was not listened to so she consulted an alternative health practitioner.

Three years following this, her wrists are painful and inflamed, and she finds driving her car painful without a rigid wrist brace. The MRI shows synovitis and erosions with the carpal (wrist) joints disrupted. She is now unemployed.

Let me make this clear.

Methotrexate is an effective medication for many conditions in rheumatology. In rheumatoid arthritis, it is a first line treatment given it’s general good safety profile for the amount of effectiveness in suppressing inflammation, at a very cheap price point.

However, it’s not a perfect medication. Far from it. Some people just cannot tolerate it.

And, we as rheumatologists, should be the first to understand this. 

There are alternatives. 

People should be made aware of this and if Methotrexate is not tolerated, it’s time to swap strategies.

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