Chase Farm Hospital, Enfield EN2 8JL, UK
Correspondence to: J. Griffin. E-mail: jane.griffin{at}cfh-tr.nthames.nhs.uk
SIR, We would wholeheartedly agree with the Leeds group [1] in advocating parenteral methotrexate therapy prior to biological therapy in rheumatoid arthritis. In the BSR working group for the biologic register, just such a suggestion was rejected because of the lack of widespread experience of this therapy and the perceived difficulty of organizing pharmacists to provide and distribute the drug.
Over the past 6 yr we have accumulated 85 patients with rheumatoid arthritis on parenteral methotrexate, given by self-injection subcutaneously or intramuscularly by a nurse in general practice. Patients unable to cope with self-injecting have usually been able to persuade a family member to administer it. Of those who decided to revert to oral medication because they disliked the injections, loss of effectiveness persuaded all but one to resume parenteral therapy.
We presented a small audit at EULAR 2002 [2], entitled Parenteral methotrexate really works. Twenty-two prospective patients switched from a mean oral dose of 17.5 mg methotrexate to parenteral therapy at the same dose. Over a 6-month period there was a significant reduction in swollen joint count (P<0.05), tender joint count (P<0.01), pain VAS (P<0.01) and patient self-assessment VAS plus the doctors global assessment VAS (both P<0.02). The steroid dose was reduced (P<0.03) and haemoglobin rose (P<0.05). There was no significant change in the HAQ score over this short period of time.
Kremer and Hamilton demonstrated that increasing the oral methotrexate dose is accompanied by proportionately less systemic absorption [3]. We strongly recommend conversion to parenteral therapy if there is difficulty in obtaining funding for biological therapy. In our unit all patients receive parenteral methotrexate before being considered for biological therapy.
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