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We read with great interest the recent letter entitled “Is parenteral methotrexate worth trying?” by Osman and Mulherin.1 There has been an increased use of intramuscular methotrexate (IM-MTX) in our department in the past two years, leading to an increased workload in the nurse-led monitoring clinics and in the cost. This has prompted us to review the clinical utility of switching patients to IM-MTX. In addition, we have recorded patients' experiences, focusing chiefly on patient satisfaction, with this treatment.
Medical case notes of 31 patients who had started treatment with IM-MTX, identified from our database, were examined. The clinical diagnosis, previous drug treatment, reason for changing to IM-MTX, efficacy, and side effects were noted. In addition, the patients were asked to complete a questionnaire, looking at patient satisfaction and preferred venue for injections (monitoring clinic or local doctor's surgery/home).
Our patient cohort was made up of 24 patients with rheumatoid arthritis, four with seronegative spondyloarthritis, two with systemic lupus erythematosus, and one with undifferentiated connective tissue disease. Most patients had been receiving a previous disease modifying antirheumatic drug (DMARD), including 24 patients taking oral MTX. Reasons for changing to IM-MTX treatment were as follows: side effects in 11 patients, loss of efficacy in 12, and poor oral compliance in eight. The median starting and maintenance doses were 10 mg weekly (range 5–17.5) and 15 mg weekly (range 10–17.5), respectively. During the study, five patients discontinued IM-MTX: two because of side effects, one developed multiple nodulosis, one did not attend for follow up, and one died from an unrelated cause. Median duration of treatment in the remaining 26 patients was 10 months (range 1–20). Significant improvement in disease activity, as measured by erythrocyte sedimentation rate and C reactive protein, was seen after three months (p<0.01), with improvement maintained after nine months (p<0.01) of IM-MTX treatment. Twenty four of the 26 current patients completed the questionnaire. On a satisfaction scale of 1–5, the average rating was 4.2, indicating that patients were either very or extremely satisfied with their IM-MTX treatment. Fourteen patients preferred their injections in the monitoring clinic, five patients preferred their local doctor's surgery, and five patients expressed no preferences. Only three patients stated that weekly clinic visits were inconvenient.
In conclusion, we found that IM-MTX was effective and well tolerated. In addition, our observations further support the switch to parenteral MTX in those patients previously intolerant or who have failed to respond to oral MTX.2 Surprisingly, most patients preferred to have their injections in the monitoring clinic. The reason for this is not clear. Possibly, the patients felt more confident if cytotoxic drugs were given by a trained healthcare professional, although a previous study by Arthur et alhas found that self injection of DMARDs is safe, convenient, and time and cost saving to the patient.3 We are currently comparing the administration of parenteral MTX in the monitoring clinic with self administration in the community. Regardless of the outcome, the role of parenteral MTX in rheumatic diseases is likely to expand and the cost and resource implications of continuing with this treatment need to be discussed.
It is gratifying that Drs Burbage, Gupta, and Lim have also demonstrated efficacy and high levels of patient satisfaction associated with parenteral methotrexate in their study. There remains a surprising dearth of reported information about this useful and widely prescribed development in rheumatology practice. Because of the burgeoning number of patients being treated in this way, it is creating increasing logistical difficulties. It represents an unlicensed use of this drug, which can cause anxiety among less experienced practitioners. Issues related to the appropriate disposal of the residual cytotoxic waste have also caused considerable difficulties. Although weekly oral methotrexate, prescribed and monitored within primary care, is an extremely cheap and effective treatment for rheumatoid arthritis, this is certainly not the case for parenteral methotrexate if it is necessary for it to be prescribed and administered in a costly secondary care setting. As primary care buckles under increasing demands on its resources, cost and logistical issues, rather than issues of efficacy, may curtail the deserved role of parenteral methotrexate in current and future rheumatology practice.
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