What’s It Worth?: The Pros and Cons of Methotrexate

We are living in an age of ever-increasing medical options. While it is wonderful to have options, the process of finding which medicine regimen works best can be daunting, and even sickening, literally.

I have been on a number of biologic drugs over the years, and I am currently taking Orencia via subcutaneous injections. I’ve been on Orencia for eight months, and while it helps, I continue to have more swelling and pain than my doctor or I would like. Therefore, a few weeks ago my doctor suggested I add Methotrexate. I have only been seeing this rheumatologist for about a year, so he asked me about my history with Methotrexate. I told him that I took it for a year or two shortly after my RA diagnosis in 2000, and that it made me nauseated and tired. However, I honestly can’t remember whether it was the side effects or a lack of efficacy that led my former rheumatologist to discontinue the medication. My new doctor stated that studies have shown that Orencia is far more effective when taken in conjunction with Methotrexate than when taken alone, so he suggested that I go back on the drug but start with half of the standard dose to minimize the risk of side effects.

I was willing to give it a try. It’s amazing how much I’d forgotten about the medication in the twelve years since I’d taken it. The first “oh yeah” moment came when I took my pill bottle out of the paper bag and saw the “Do Not Drink Alcohol While Taking This Medication” sticker my pharmacist had placed on the cap. While I have congratulated myself for the year I spent abstaining from alcohol early in the millennium, by memory had morphed the reason for the abstention to an effort to improve my RA, not because of the increased risk for liver damage that combining alcohol and Methotrexate use causes. Somehow I had forgotten all about both the risks for the liver and the subsequent need for regular blood tests to test liver function. I was disappointed in having my memory refreshed by that pharmacy label. While I’m not a heavy drinker, I love having a glass (or two) of wine after a long day of working in a public school and keeping up with my 2 and 4-year olds. I called my doctor, and he said it would be okay for me to have a daily glass of wine, but not to have more than that. However, knowing that I might be damaging my liver has definitely taken away some of the relaxation benefits of wine, and I’m experimenting with seeing if increased exercise can replace the desire for that evening glass of Pinot.

The next issue to contend with has been the side effects. My rheumatologist had hoped that taking a half dose of the medication would leave me free of any side effects, but that has not proven to be the case. Every week I spend 8-12 hours feeling nauseated and exhausted. I have tried to time taking the pills so that my side effects would occur on Saturday nights (in hopes that I would sleep through them with the help of Zofran or Phenergan, the latter of which really knocks me out). However, one week the nausea will set in 24 hours after I take the drug, another week it will have a 30 hour delay, and last week the nausea developed only 12 hours after I took my medication. My husband sees how rotten I feel on my “Methotrexate weekends,” and has questioned whether it’s worth it. Of course I keep asking myself the same question.

At this point, my evaluation is that I have to allow time to find out whether the one-two punch of the Orencia and Methotrexate combo will make a huge difference in my RA. If it does, I have to think about the long game. Those of us with rheumatoid arthritis don’t just have our current symptoms to think about, but also the potential long-term deterioration of our joints. I hate feeling nauseated and lethargic each week, however I’ll also hate it if I have to have surgeries down the road. Living with RA is a constant balancing act, and it will take a little more time to see whether Methotrexate ends up with pros that outweigh the cons, or vice versa.

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