How to overcome the nausea related to Methotrexate?

Methotrexate is a wonderful drug for Rheumatoid arthritis. However, the nausea associated with the same can be quite a disturbing problem. At times, it is so severe that one has to discontinue methotrexate despite the relief provided by it.

Can you overcome the nausea related to Methotrexate?

Yes! here are a few tips—

1) Spread out the Methotrexate dose- The total dose of Methotrexate can be divided & taken over 2 days every week. For eg. You may take 1 tablet of methotrexate (5mg) after lunch & dinner on Saturday & Sunday instead of the entire dose once on Sunday.

2) You may take the dose at bedtime if the dose after lunch is causing nausea.

3) Take the dose after food instead of taking it before food.

4) You may take an antiemetic medicine along with Methotrexate.

5) Take folic acid on the all days except the day of methotrexate.

6) Acupressure:
According to traditional chinese medicine, a point called as Pericardium 6 helps relieve nausea.
It is located on the inside of the wrist, about 3 fingerwidths up from the center of the 1st wrist crease.
A person can press on the point using the index finger of the opposite hand.
Acupressure wrist bands with a bead/ button to press on this point are available.

7) If nothing works, you can shift over to injection Methotrexate. A Family Physician can administer it to you (intramuscular) or you can take it yourself subcutaneously (just like insulin shots). Even this could be impossible as in the case of one of my patients who used to get nausea even by looking at the Methotrexate vial. Her relatives never believed her story & considered the same ‘all in the head’! After months of struggling with the injections, she has found a way out. The injections are now kept by her relatives in the Family Physician’s refrigerator & he administers it to her without showing her the vial! Believe me, the trick worked.

If you have any such tricks/ experiences feel free to share the same here.

Do all patients with Rheumatoid arthritis fare badly?

Why am I thinking about this?

Because there are different categories of patients… Some who respond well, some moderately while some may not respond despite adequate treatment. Coupled with this is the emotional component which adds to the physical trauma/ disabilities that these patients may face.

Rheumatoid arthritis patients can be classified into three types based on their progression.  They are

1)      Spontaneous remission- Remission is a symptom free state with no inflammation in any of the joints.  Patients with spontaneous remission are very low in numbers, probably 5- 10%.  Many of them would have a flare at some time or the other.

2)      Relapse & remit type: The most common RA type with patients go into remission with DMARDs & have an occasional flare.  Thankfully, this is the most common types & accounts for almost 60- 70% of the patients.

3)      Progressive type:  This type of patients remains in the persistent flare up stage & tends to progress despite treatment. These are the difficult patients & account for 10- 20% of the entire RA population.

Given these numbers, everyone need not really fare badly with RA. The numbers are definitely on your side to do well & get into remission.

Medically speaking, we have taken major strides as far as the RA treatment & outcome of patients is concerned.  We had started with no options other than steroids to begin with.  Methotrexate was the first wave. Leflunomide the second & the biologics are the third wave.

Apart from this, the approach to the treatment has seen a major paradigm shift over the years. We have shifted radically from the conservative traditional ‘wait and watch’ approach to a very aggressive approach. COBRA & Fin-RA studies were the first to start the concept of combining multiple DMARDs rather than treating with a single drug. This was at a time when RA was considered a benign disease & drugs were considered to cause more harm than good.  We have come a long way since then.

These studies had remission rate of about 25% at one year. Pathetic, I am sure, for a disease like RA. All it goes to say is that only 25% of the patients would be able to achieve remission given the best available treatment strategy at that time.  The resent TICORA study published in 2004, came up with the concept of aggressive & intensive therapy approach showed a EULAR good response rate of 82%. This is definitely a big jump in numbers. Today, we can proudly say that we have progressed to a stage wherein, the proportion of patients going improve significantly with therapy has gone up from a mere 25% to 82%.

So, even if you are diagnosed to have RA, there is no need to panic. You have numbers on your side… you should definitely do well if managed properly.    

Ref:

1)Boers M, Verhoeven AC, Markusse HM, et al. Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet (1997) 350:309–18

2)Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. The Lancet, Volume 364, Issue 9430, Pages 263 – 269. 2004 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16676-2/abstract

 RA- Rheumatoid arthritis

DMARDs- Disease Modifying Anti Rheumatic Drugs

Conquering Rheumatoid arthritis

That Rheumatoid Arthritis is a serious & disabling condition is fairly well known. However, it often comes as a surprise to many when informed that it is also controllable. We should consider ourselves blessed when compared to our forefathers given the recent treatment options & outcome of rheumatoid arthritis.

One can achieve conquest over Rheumatoid Arthritis when diagnosed & treated early with definite medicines (DMARDs).

The problems with early diagnosis are manifold. Joint complaints are often ignored in the initial stages. The current medical educational system lays emphasis on obvious emergencies & life threatening diseases like heart attack, stroke & infectious diseases like tuberculosis. Thus many of the Family physicians are not well trained in early diagnosis of Rheumatoid arthritis. I’m sure it remains a big responsibility of the Rheumatologist fraternity along with the academic bodies to look after training of the family physicians in musculoskeletal ailments.

Many patients thus end up wasting precious time at this first step of contact with the primary caretaker. Frustration over their complaints & inappropriate guidance may lead them to alternative systems. The Indian system is plagued with numerous ‘so called traditional system doctors’ who administer steroids & spoil the long term prognosis for them. Quick suspicion & immediate referral by a family physician to a Rheumatologist will definitely change their life.

The second step for these patients is accessing a Rheumatologist. I must confess that Rheumatologists are too few & everyone has a long waiting list. A 6- 8 weeks appointment delay obviously eats into the therapeutic window of RA patients. Time is lost at the cost of joint function in these patients. It remains a collective responsibility of us Rheumatologists to bear this in mind so as to maintain the least possible waiting period for a new RA patient.

The next step at the Rheumatologist’s can be plagued by its own set of problems. The first & foremost is the self denial of diagnosis. The myths about arthritis in the society, the so called uncontrollable nature of RA plays an important role in this denial. A gentle reassurance by the Rheumatologist & interaction with old patients in the clinic generally allay the initial fears. The general fear that treatment is based on steroids often plays a spoilsport at this step. All recent research studies have shown that early & aggressive treatment with DMARDs (like Methotrexate, Leflunomide etc) leads to remission.

The time from onset of symptoms to control of RA activity remains the main determinant of the conquest over Rheumatoid Arthritis. Many patients falter at each of these steps & fall into the nadir of the never ending pain of rheumatoid arthritis. The family physician, Rheumatologist & the society share their own set of responsibilities in helping these patients achieve conquest over their arthritis.