“No” to More MTX
I am responding to your column inviting comment on raising Mr. Jones’ methotrexate (MTX) to 17.5 (July 2011, p. 9). I disagree.
In my practice, risk, not efficacy, is usually the determining factor in most decisions. Patients are highly risk averse. They hear on TV that a certain drug may cause diarrhea, or the same drug may cause constipation, another drug may cause sleepiness, or it may cause insomnia, the next drug may cause “TTP, which is often fatal.” (Partly because only a small minority of physicians can recognize TTP; thankfully, rheumatologists usually can.)
When Mr. Jones first started on MTX, he might have been handed a “fact sheet” by a 23-year-old pharmacy technician filled with erroneous facts about MTX, and the tech might have also said that she had called the doctor because the computer told her that MTX combined with an NSAID is possibly fatal (and the doctor annoyingly told her that her information is 50 years out of date). It probably scared Mr. Jones and certainly scared his spouse.
Or, he got a clipping from his sister-in-law in Denver about the risks of MTX, but she did not know it was written by a guy selling topical chondroitin sulfate at $32 a tube who was dedicated to disparaging mainstream medical care.
You may make decisions based on the natural logarithm of the sed rate, but like Allan Gibofsky has quipped, old dogs like me use the “Brooklyn HAQ,” which is epitomized as, “How ‘ya doing, Mrs. Schwartz?” Mr. Jones has already told you that he is much, much better and is leading a normal life. When I say to a patient, as I often do, “Are you satisfied with the degree of improvement, or should we get more aggressive, even if it might increase the risks of side effects?”, almost everyone—and certainly your Mr. Jones—would say, Leave the status quo. Raising his MTX dose will not lower his golf handicap.
It is a well-kept secret in rheumatology that MTX in the doses we use (with a few safeguards) is basically innocuous in almost everybody. I would have decreased his steroids and maybe substituted an NSAID, perhaps two. (I routinely use two at a time.)
And, if you would like to debate the putative risks of NSAIDs, I am up for the task. Increase the MTX in this case—NEVER!
Robert Greenwald, MD – ProHealth Care Associates
Lake Success, N.Y.
T2T and the DAS
As always, a thoughtful piece on T2T (July 2011, p. 9). A few comments:
- Our colleagues from Nijmegen have a site that, I think, is not sponsored by pharma, and includes everything you ever wanted to know (or perhaps not) on the DAS: www.das-score.nl. It does come up on Google but isn’t the first hit.
- The DAS was made 20 years ago and the score was optimized to distinguish active from inactive RA, defined as treatment changed for disease activity, or treatment not changed. As this was 20 years ago, average activity levels were much higher (around DAS28 of 4 or higher), and the target was also. It is, perhaps, unfair to expect the instrument to work as well at the much lower disease activity levels we are seeing today, at least where access to modern treatment exists. It is quite common to be baffled by DAS results at low disease activity levels, where ESR changes in the normal range strongly drive the DAS result. This is also the reason DAS is not recommended for use to define remission in the new criteria.
- Your case is a hard call, but if it were easy, why present it? I think with Mr. Jones, who evidently has little to complain of, I would have sought additional information from radiographs. A few joints that remain swollen but are not painful and do not show progression on X-ray (say, in a year’s time) would probably have led me to suggest to the patient that we would wait and see rather than intensify treatment. Return of pain or damage progression would have led me to follow the course you did.
Maarten Boers, MSc, MD, PhD – Professor of Clinical Epidemiology Department of Epidemiology and Biostatistics VU University Medical Center
Amsterdam, Netherlands
Autoimmune versus Infection
Regarding the article on autoimmune syndrome by Yehuda Shoenfeld, MD (“ASIA: A New Way to Put the Puzzle Together,” June 2011, p. 1), the article states that this 56-year-old female “was diagnosed with chronic fatigue, fibromyalgia, weakness, headaches, difficulties concentrating, short-term memory impairment, and evidence of demyelinating illness.” All of these symptoms are seen in Lyme disease. Was this patient tested with a Western Blot for Lyme disease? Infectious etiologies are often forgotten when the focus becomes “autoimmune.”
Alfred Miller, MD – Rheumatologist, private practice, retired
San Antonio, Texas
From the Editors: The patient in Dr. Shoenfeld’s article was seen in Israel, where Lyme disease is not endemic, and so it was not factored in as a possible diagnosis. For patients who live in or visit areas where Lyme disease is common, this infections etiology should be considered among possible diagnoses.
High Cost, but Is There No Benefit?
I read with interest the article entitled, “High Cost, No Benefit” (July 2011, p. 12). While I agree that the promotion of some “generics-plus” medications may be wasteful of already limited healthcare resources, I do believe there is occasional benefit to reinventing an old drug with a new twist.
Dr. Abeles cites an example of the many faces of diclofenac. Over the past several years, three topical formulations of diclofenac have come to market—Flector Patch, Voltaren gel, and most recently, Pennsaid. In our current clinical environment where oral NSAIDs are often taboo for our patients who need them most, these topical diclofenac variants with limited systemic absorption are welcome alternatives. I use them frequently (and sparingly) in my patients with renal disease, gastrointestinal disease, and cardiovascular disease, including those on anticoagulant and antiplatelet therapies who could not otherwise take oral NSAIDs. I find these particular “generics-plus” medications to fulfill a significant unmet need for my patients.
Thus, I believe the pharmaceutical industry should continue to strike a balance between research and development for novel therapeutics and creative innovation of currently available medications to make them more tolerable and useful for our patients. That being stated, I wholeheartedly agree that we should not be prescribing luxury generic drugs in lieu of their more economical alternatives, when clinically suitable. In my practice, insurance-mandated step therapy usually precludes such prescribing, anyway. I believe that our collective clinical judgment ultimately dictates the market for which “generics-plus” medications are useful versus wasteful.
Deborah R. Alpert, MD, PhD – Clinical Assistant Professor of Medicine Section of Rheumatology, Department of Medicine Jersey Shore University Medical Center
Neptune, N.J.
