Tag Archive | Methotrexate

Methotrexate for Knee OA?

Maybe—but only if larger, longer-term studies replicate the findings from a randomized trial of 144 patients (mean age = 66 years) published recently in the Annals of the Rheumatic Diseases.

Subjects with knee osteoarthritis (OA) in the double-blind Annals study received either placebo or up to 25 mg per week of oral methotrexate over a 28-week period. At 28 weeks, researchers found greater reductions in knee pain and larger improvements in scores of physical function and activities of daily living in the methotrexate group than in the placebo group. The authors also noted a significantly greater reduction in synovitis, measured both clinically and with ultrasound, in the methotrexate group relative to the placebo group.

Methotrexate is a powerful drug prescribed to treat certain cancers and refractory rheumatoid arthritis, but it has many well-known and potentially serious side effects, such as hematopoietic suppression and liver toxicity. Nevertheless, these authors reported few adverse events; those that did occur included self-limiting mucositis, alopecia, GI disturbance, and transaminitis.

While some people are thought to have a more inflammatory phenotype of osteoarthritis than others, this study did not stratify patients along inflammatory lines, so further research will be needed to determine whether methotrexate’s clinical benefits accrue equally to OA patients generally, or mostly to those with the inflammatory subtype.

Stopping DMARDs Often Unnecessary for RA Patients Prior to Orthopaedic Surgery

Most patients with rheumatoid arthritis (RA) will undergo orthopaedic surgery during the course of their disease, and more than 80% of that cohort will be taking traditional or biologic disease-modifying antirheumatic drugs (DMARDs) at the time of their operations. That presents a dilemma, because stopping DMARDs can raise the risk of a rehab-hampering postoperative RA flare, while continuing the drugs is thought to increase the risk of postoperative infection.

A recent literature review in Seminars in Arthritis & Rheumatism suggests that surgeons should feel comfortable allowing patients to continue taking traditional DMARDs, such as sulfasalazine, as long as renal function is monitored. Emphasizing that more research is needed to pinpoint optimal start and stop dates for other DMARDs, review author Susan Goodman, MD, makes the following suggestions:

–Methotrexate: Continuing is recommended.

–Leflunomide: Discontinue for 1 week prior to surgery.

–Anti-TNF Alpha Drugs: Withhold therapy for 1.5 times the dosing interval.

–Tocilizumab: Exercise increased vigilance due to possible masking of signs of infection.

–Abatacept: Withhold for 2 to 3 weeks prior to surgery.

–Tofacitinib: Withhold for 2 days prior to surgery.

Dr. Goodman also observes that preoperative doses of corticosteroids, often used to cover RA flares in patients who’ve discontinued DMARDS, are often far higher than necessary, which could also increase infection risk.