Parenteral methotrexate should be given before biological therapy

A. J. Griffin and F. Erkeller-Yuksel

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 doctor’s 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.

References

  1. Bingham SJ, Buch MH, Lindsay S, Pollard A, White J, Emery P. Parenteral methotrexate should be given before biological therapy. Rheumatology 2003;42:1009–10.[Free Full Text]
  2. Erkeller-Yuksel FM, Griffin AJ. Parenteral methotrexate really works. Ann Rheum Dis 2003;61(Suppl. 1):209.
  3. Hamilton RA, Kremer JM. Why intramuscular methotrexate may be more efficacious than oral dosing in patients with rheumatoid arthritis. Br J Rheumatol 1997;36:86–90.[CrossRef][ISI][Medline]
Accepted 12 November 2003





This Article
Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Griffin, A. J.
Articles by Erkeller-Yuksel, F.
PubMed
PubMed Citation
Articles by Griffin, A. J.
Articles by Erkeller-Yuksel, F.
Related Collections
Rheumatoid Arthritis