Find the Right Medication and Manage Side Effects
Jane, who was just diagnosed with rheumatoid arthritis by her new rheumatology doctor, has been started on oral weekly methotrexate (Rheumatrex, Trexall) tablets. The doctor had a discussion with her about potential side effects of methotrexate, including hair thinning, mouth sores, rash, bone marrow injury, low blood counts, and liver injury. It was explained that the side effects of methotrexate can be reduced by taking supplemental folic acid. In addition, she was told that regular blood testing is mandatory while taking methotrexate to monitor for signs of bone marrow or liver toxicity. Moreover, the doctor asked about potential pregnancy (because methotrexate cannot be taken during pregnancy) and was informed that this was not possible as she had had tubal ligations after her second child three years ago. Finally, she was told that methotrexate would take some weeks to months to attain maximum benefits. She was the perfect candidate for methotrexate, a "gold standard" in the treatment of rheumatoid arthritis.
Additionally, Jane was started on low-dose prednisone (Deltasone, Liquid Pred) medication as a "bridge" to reduce inflammation, pain, and stiffness, as well as restore function until methotrexate took over. She was also informed about the potential side effects of this cortisone medication, including weight gain, blood pressure elevation, easy bruising, irritability, insomnia, cataracts, and osteoporosis. And it was noted that these side effects were less likely at the lower doses and that she would be weaning off prednisone soon.
When she met with the rheumatologist four weeks later, she was feeling dramatically better. Her stiffness was now under 30 minutes, and her pain level had reduced from "9" to "2" on a scale of "10." She had resumed her normal duties at work as of two weeks ago. Her interim blood tests were normal, and she was told to reduce her prednisone while maintaining her methotrexate and folic acid. She was recommended to gradually begin an exercise program and to take calcium and vitamin D supplementation to strengthen her muscles and minimize risks of osteoporosis.
She was seen regularly over the next six months. Just over half a year after first treatment for her rheumatoid arthritis, she was at full function and had no joint symptoms. She had been off of prednisone for several months and was only taking maintenance methotrexate and folic acid. She and her husband planned a vacation to Hawaii. A trip that included hiking and parasailing!
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Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. 13th ed. New York: Springer and Arthritis Foundation, 2008.