Yesterday I got to visit with my rheumatologist again. After 2 weeks on the prednisone, I was seeing little relief from my pain. The stiffness in the morning was letting up a bit, but my painful joints were only increasing. As stress increases in my life (and with 2 kids, a husband, and full time job, when does stress let up?), my pain also seems to increase. I also have noticed that with rain and these cooler days, my pain and stiffness make a full return. Being cool AND rainy yesterday, I had a rough morning of sore/painful shoulders, hips, knees, hands and feet. I feel like I'm getting old! It is tough to feel slow. In addition to the physical symptoms, the inflammation seems to suppress my appetite. If I don't force myself, I would probably be fine just eating one meal a day. The thought of eating turns my stomach. Not a good thing when I am tired to begin with. Hopefully this symptom will work it's way out as well. I need my strength!
So the doctor was great to hear our concerns about how I have been doing and some things going on in our lives. We decided to begin on a bit more aggressive drug to help hopefully slow the progression of the RA. At this point, my xrays look good and I do not have any joint damage. That is the goal to keep it that way. The drug I am taking now, methotrexate, should help to slow the progression by supressing my immune system. A few things about it...it was not created as an RA drug. It actually is a chemo drug, but I am taking it at a low dose. Kind of scary hearing chemo though. Here's a really great listing of more about it and what it should do...
Methotrexate is now considered the first-line DMARD agent for most patients with RA. It has a relatively rapid onset of action at therapeutic doses (6-8 weeks), good efficacy, favorable toxicity profile, ease of administration, and relatively low cost. When looking at groups of patients on different DMARDS, the majority of patients continue to take Methotrexate after 5 years, far more than other therapies reflecting both its efficacy and tolerability. Methotrexate is effective in reducing the signs and symptoms of RA, as well as slowing or halting radiographic damage. It was as effective as leflunomide and sulfasalazine in one study, and its effectiveness given early and in higher doses approached the efficacy of etanercept and adalimumab as single therapies in terms of signs and symptom improvement. Methotrexate is also effective in many other forms of inflammatory arthritis including psoriatic arthritis and other spondyloarthopathies, and is used in many other autoimmune diseases.
Mechanism:
The anti-inflammatory effects of methotrexate in rheumatoid arthritis appear to be related at least in part to interruption of adenosine and possible effects on TNF pathways. The immunosuppressive and toxic effects of methotrexate are due to the inhibition of an enzyme involved in the metabolism of folic acid, dihydrofolate reductase.
Dosage:
In a study comparing methotrexate to etanercept in early RA, methotrexate was started at a dose of 10 mg per week, and increased to 20 mg per week by week 8. This dosing regimen or regimens that start at even higher doses (up to 15 mg per week) with a dose escalation to 20 mg within the first three months is now fairly well accepted in clinical practice. Maximal dose is usually 25 mg per week but is sometimes increased further. Methotrexate can be given orally or by subcutaneous injection. The latter route of administration can be advantageous for patients who have methotrexate-associated nausea. Patients starting methotrexate should be carefully evaluated for renal insufficiency, acute or chronic liver disease, significant alcohol intake or alcohol abuse, leukopenia (low white blood cell counts), thrombocytopenia (low platelet counts), or untreated folate deficiency. Obesity, diabetes and history of hepatitis B or C are factors that have been suggested but not confirmed to increase methotrexate hepatotoxicity (liver injury). Salicylates (and other NSAIDs) and the antibiotic trimethoprim (Bactrim®, Septra®) block the renal excretion of methotrexate and increase serum levels with an increased risk of toxicity. If alternatives exist, concomitant use of methotrexate and trimethoprim is to be avoided. The coadministration of NSAIDS with methotrexate is routine in patients with rheumatoid arthritis and is considered safe by rheumatologists as long as liver function tests are closely monitored.
Side Effects:
Fortunately the most serious complications of methotrexate therapy: hepatic cirrhosis, interstitial pneumonitis, and severe myelosuppression are quite rare, especially with proper monitoring. Stomatitis and oral ulcers, mild alopecia and hair thinning, and GI upset may occur and are related to folic acid antagonism. These side effects can be improved with folic acid supplementation. Folic acid given at a dose of 1mg daily does not diminish the efficacy of methotrexate and is routinely given with methotrexate to decrease these side effects. Some patients complain of headache, fatigue, and feeling “wiped out” (also called methotrexate “fog”). These side effects can often be overcome by increasing folic acid or using an activated form of folic acid known as folinic acid (leukovorin®) given as a 5mg dose 12 hours and sometimes 24 hours after methotrexate is given.
Some patients complain of GI upset (nausea or diarrhea) with oral methotrexate. This may be lessened when methotrexate is taken at night. In most cases this is completely eliminated when methotrexate is given by subcutaneous administration.
Courtesy of: The John Hopkins Arthritis Treatment Center
See also:
One of the possible side effects is liver damage. I will have to go for blood tests every 4 weeks to have that checked. I could also have thinning of my hair. I've been debating what to do with my hair. With my hands being painful and especially sore in the mornings, I'm really thinking about doing a drastic chop of it all. I might also have some nausea. This might not be good as I already have little appetite. So far though, I have taken half of my first dose and all seems okay. I take 6 pills once a week to avoid toxicity. I know, crazy.
The drug may take a few weeks to show its effect, if it is going to have any. I go back to my rheumy in 6 weeks to follow up and see if we need to make any changes.
This has been a lot for us to swallow. But, we have to trust the doctor and treat this aggressively. I want to avoid disfiguration and disability as much as we can! This disease is aggressive and mean. We have to act first!
