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Combining Methotrexate and Biologics
from Joanne K.

Hi Ed:  I started Raptiva about 4 months ago. After 6 weeks I developed severe swelling in my lower legs and feet, which also was accompanied by a severe outbreak of guttate plaques.

My doctor told me to use MTX (methotrexate, 15mg/wk) with the Raptiva, and after 2 weeks I saw an amazing improvement. After 4 more weeks I was virtually clear. Great!

Then I tapered off the MTX, and after 6 weeks off MTX I again started to get a bad guttate reaction.

Now I have just added back a low dose MTX (10 mg/wk) and already, after 1 week, it appears to be heading back to it's former glory (clearing).

Does anybody have any experience with combining MTX and Biologics?

Thanks -Joanne K.

*****

Ed’s Response:   I have heard about combining the biologics with other systemics (e.g., see Combining Enbrel and Systemics).  This apparently is being prescribed when the biologic is helping but not sufficiently.  As our current crop of biologics each target a very narrow activity within the immune system, and as we’re learning a chain of related-but-discrete immune system malfunctions may add up to P, it’s not surprising that only one biologic may be insufficient for some percentage of us. 

I’ve read that in some places derms are experimenting with combining biologics.  Lord, what an expensive proposition!  It’s more financially practical to add a small dose of a toxic systemic — like methotrexate — to the regimen than to add more biologics. 

I’ve heard from very few people who have found 10-15 mgs of methotrexate alone clears them (though some can be “maintained” for a number of months after clearance on these low doses).  The ability to obtain clearance on 15 mgs or less when combined with the biologic makes methotrexate a much “kinder and gentler” addition to your treatment plan (at 25 to 30 mgs/week its toxicity is of greater concern).

I’m scheduled to switch biologics this month (Jan ’06) in an attempt to find a single biologic to palliate both my skin and my joints.  If that doesn’t work, I think I’ll talk seriously with my derm and rheumy about trying a biologic/methotrexate combo.  When I was using methotrexate alone for my P, I was taking 30 mgs weekly to obtain clearance, then 25 mgs weekly to maintain clearance — and I never did obtain complete clearance.  At those levels everyone was concerned about liver damage, but I never exhibited any symptoms, I had blood work done every other month, and I had a liver biopsy that revealed “no problems” when my accumulated dosage reached 1,500 mgs.  All of this means a return to methotrexate at a dosage roughly half that of former times is probably very safe for me — but will it actually help me?  Perhaps I’ll be trying to answer that question in the not too distant future.

Meanwhile, Joanne, please let us know if you try the combined regimen and how you fare.  -Ed

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