Is It Possible To Take Less Methotrexate?
Methotrexate - a common RA treatment
Methotrexate is probably the most commonly prescribed drug for rheumatoid arthritis. It might be used alone or taken as part of the “triple therapy” approach that combines methotrexate, Plaquenil, and sulfasalazine. Methotrexate can also be taken in combination with some of the RA biologics, such as rituximab or Remicade.
I’ve been taking methotrexate since my RA diagnosis in 2007 and it has worked well for me. It’s difficult to remember, 10 years later, but I’m sure that I started at a low dose and gradually worked my way up to the current dose of 25mg/week. I’ve been using this maximum dose for years, except for a recent attempt to lower the dose.
Oral methotrexate comes in 2.5mg tablets which allows for easy adjustment of the dose. Some people may only take 4 tablets each week, while others take up to 10 tablets. For patients who cannot tolerate the oral medication, or who may need increased effectiveness, injectable methotrexate is available.
Eighteen months ago when I needed to find a new rheumatologist because my previous doctor retired, it was important to find someone who would continue my current treatment protocol. I didn’t want to make any changes.
During our initial appointment, it became clear that she was agreeable to this arrangement. However, she did ask me about my methotrexate dose. She suggested that we could consider lowering the dose.
"The less medication needed to be effective is always good,” she says. I wasn’t interested in making any changes and she agreed that perhaps winter wasn’t the optimum time to experiment.
But last September during our appointment, she suggested the possibility of trying a lower dose. This time I was willing to attempt it. At first, I lowered my dose to 9 tablets per week; then after several weeks, I went down to 8 tablets per week.
This was probably not the optimum time to experiment because I was still in the middle of the episcleritis flare (which ultimately lasted for 9 weeks). Initially, things seemed unchanged. Then I started to experience more stiffness, more pain, more difficulties overall.
In December, I called the office to talk to my rheumatologist. I was in the middle of a mild RA flare. She was on vacation, but thankfully her colleague called me in a steroid taper. I don’t like steroids, but they certainly to help.
After this, I decided that even a modestly lower dose of methotrexate was probably not the best idea. I promptly went back to my longtime 25mg/week routine.
This week, I had an appointment with my rheumatologist and reported that this “experiment” was a failure. This time she offered the injectable form of methotrexate. But since I don’t have problems with side-effects with the oral form — some people experience nausea and gastrointestinal issues — I’m happy enough to continue with my weekly pills.
This recent experience reminded me of the time that I attempted to taper down off of methotrexate with the idea that maybe I might want to have children. That experiment failed as well, albeit in a more dramatic way. It only took a few weeks before significant pain and swelling returned. Evidently, I am one of those people who needs to take more than one RA drug — in my case, rituximab and methotrexate.
What has been your experience with methotrexate? Have you tried to lower your dose? What happened?
Please share in the comments.
Do you find the pain scale is an effective tool?