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When to Start Methotrexate?
from Lynn

Hi Ed:  I've just started reading some of the postings on your site and found them to be really useful.  Like so many others, I am in my early 30s, having suffered from psoriasis for about 10 years now, but only recently discovered signs of joint pain.  Because I'm only experiencing “annoying” joint pain in my knees, which my rheum and I attribute to a mild case of PA.  I am very fearful that the PA, if left untreated, will become worse and debilitating.

I’m considering the drug, methotrexate, but it is something I've so far avoided due to the lifestyle changes it requires, like not being able to drink, etc.  Anyway, I have a question for you and others:  When would you suggest beginning on something like methotrexate for the treatment of PA? 

You said in one of your past emails that you wouldn't recommend methotrexate to anyone unless the pain was getting "debilitating."  But since PA is a progressive disease, doesn't it make more sense to apply a more aggressive strategy to "nipping the disease in the bud" and using methotrexate while the disease is still just in it's "annoying" stage, rather than wait until it has become more severe and potentially have already caused irreversible joint damage? 

That is the issue with which I'm struggling.   I don't want irreversible joint damage, but because the pain hasn't been debilitating I keep putting off the decision to go on methotrexate.  Any thoughts?

Thanks. -Lynn

*****

Ed’s Response:  Thanks for asking the question, Lynn.  It gives me a chance to perhaps necessarily qualify what I said earlier.  The reason I would recommend postponing the use of methotrexate until the pain of PA becomes debilitating (i.e., severely affects one’s lifestyle) is it is a drug few people end up taking “forever.” 

Many people take methotrexate (MTX) for many years; others take it for only a few months before its adverse effect on their livers compel them to stop.  I don’t know of any way doctors can “anticipate” how any particular patient will respond to prolonged MTX therapy. 

On the other hand, MTX tends to work well for most people with PA, which means the chances that it will make a debilitating condition bearable are good.  Assuming the worst, that you will only be able to use MTX for a few years, would you like to benefit from it when your PA is mild or severe?

As long as I could walk and drive and handle the pain of PA with Vioxx, I, personally, did not feel compelled to take MTX.  When the Vioxx stopped working well, when I could not drive and required a cane to walk, that’s when I started MTX.

Frankly, I did not consider “irreversible damage” to my joints.  Nor did my rheumatologist or dermatologist ever say anything to me about damage being “irreversible.”  Is PA or any other form of arthritis truly reversible? I’m not an authority on arthritis of any kind, but I’ve been led to understand irreversible damage comes when joint tissues erode and the actual physical structure of the joint changes.  What I would call “debilitating” comes before this happens.  It was pain that debilitated me — made driving impossible and walking agonizing — but I was probably far from the advanced stage of joint degeneration.   The MTX completely restored my mobility.  

Also, I don't believe MTX necessarily inhibits or stops joint erosion.  Ask your rheumatologist.  I basing this on my reading of this article at the NPF web site.

But that’s me and that was then.  MTX isn’t the only alternative, now.  Enbrel and Remicade may be possibilities for you and you should certainly talk to your doctors about them before deciding on methotrexate.  As I write this I am phasing off my second go at MTX and starting Enbrel therapy.  I am also (on an orthopedist’s advice) taking a daily dose of glucosamine and chondroitin.  Time will tell.

Discuss what “debilitating” means to you and your rheumatologist, Lynn.  Your doc may not share my fear about using up your limited time on methotrexate before you might really need it. 

In any case, do please let us know where you go from here.  -Ed

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