Does the prospective father need to stop Methotrexate?

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MethotrexateDr Irwin Lim, Rheumatologist

Received an email from Kay, which I’m sharing with her permission:

“My partner has been taking Methotrexate (Methoblastin) for Psoriasis for an extended period of time.  I believe that the dose is 20mg per week.

Are you aware of any referenced evidence or trials relating to birth defects where the male partner has been taking Methotrexate at the point of conception?  

I am having a lot of trouble finding any detailed information about this topic though I did find one forum where there was a broad indication that there is no real evidence in this situation and claims by some women that they have given birth to babies with no defects despite their partners treatment.  

I really can’t see my partner being able to come off the drug for the three months that the pharmaceutical manufacturers recommend as he suffers a lot of pain within about two weeks of stopping.

We have been very conscious about the potential side effects and so have been very careful to not get pregnant – unfortunately, not careful enough.”

She’s obviously quite concerned by the situation, which is fair enough, given the general recommendation is to cease Methotrexate in both females, and males, prior to trying to conceive.

I think it’s clearly accepted that the prospective mother should cease Methotrexate, usually for a period of 3 months, prior to falling pregnant. The situation with males should be different, given their obviously different role in pregnancy.

My response to Kay was:

“I am not aware of any known case where a male patient continued on Methotrexate and then this led to a birth detect. Please do understand that birth defects do occur at a background rate in people not on medications as well.

I do know that the recommendation is for the male to cease Methotrexate prior to attempting conception but I do not think this is based on any scientific evidence. Rather it is based on avoiding litigation from distraught parents.

I have not insisted that my male patients stop their Methotrexate and have been privy to patients conceiving healthy babies while the male patient continued on Methotrexate.

Hopefully, this helps you. You and your husband should discuss this in much more detail with the treating rheumatologist.”

Kay also highlighted 2 very useful fact sheets from OTIS (Organization of Teratology Information Specialists):

https://www.mothertobaby.org/files/methotrexate.pdf
http://www.mothertobaby.org/files/paternal.pdf

I thought it worth opening up this topic for discussion here.

What are your experiences with this issue, either as a patient, a partner, or a health care professional?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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Can TNFi for Psoriatic Arthritis worsen Psoriasis?

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Psoriasis

By Dr Irwin Lim, Rheumatologist

Tumor Necrosis Factor inhibitors (TNFi) have been used for more than a decade as effective treatment for a variety of inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, inflammatory bowel disease and psoriasis/psoriatic arthritis.

IMG_3698Many patient with psoriasis show rapid and marked response in their skin lesions with TNFi therapy. This is what I as a rheumatologist would expect and tell my patients with psoriatic arthritis when I commence them on TNFi therapy.

Paradoxically, some patients, even when their psoriatic arthritis manifestations improve (these include spinal pain, joint swelling, enthesitis and tendon inflammation), develop worsening psoriasis or new psoriasis-type skin lesions.

These psoriasis-type or psoriasiform lesions have been reported in patients with the range of different diseases treated with these TNFi agents. They’ve also occurred with the full range of different TNFi medications.

The most common lesions are plaque and palmopustular psoriasis but a small number of patients have also presented with guttate lesions.

IMG_3700The lesions can occur anytime following initiation of the TNFi, weeks or years after.

You can appreciate that in the small minority who do develop these skin lesions that the management can be difficult, especially if the drug is working effectively to control whichever disease it was started for.

Management options include:

  • Making the diagnosis. Infection needs to be rules out and we need to work with a dermatologist as a skin biopsy may be very useful.
  • A variety of topical treatment (corticosteroid or vitamin D derivative creams or ointments) are often required.
  • If the psoriasiform lesions are severe or distressing for the patients, discontinuation of the TNFi is recommended.
  • Therapies including phototherapy, methotrexate, acitretin and cyclosporine may be required.
  • If the lesions are less severe, a switch to another TNFi medication can result in improvement. This response varies from patient to patient and is not predictable.
  •  Swapping to a different class of medication with a different mode of action, ie non-TNFi

Have you experience paradoxical psoriasiform lesions on TNFi therapy?

How did you deal with it?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Young Man, Swollen Knee

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Swollen Knee

By Dr Irwin Lim, Rheumatologist

Young 20-something year-old man walks into their health professional’s clinic.

“My right knee just started to become painful and a few days later, the swelling just grew”.

Sure, he’s an active guy and plays sport like many do.

But, the answer is not always sport.

What’s the question that should come to mind?

Is this due to mechanical/degenerative disease or it there an underlying inflammatory arthritis?

If there’s a history of trauma or there was a distinct injury on the football field with him limping off, you may be more worried about mechanical issues, for eg, a ligament tear.

If he’s had multiple injuries over a period of time in that same knee, and has known damage there, you will be considering possible mechanical and degenerative reasons for this swelling.

If you don’t have the above, consider an inflammatory arthritis cause!

How to work out what the cause is?

Well, we’d rely on a combination of:

  • a full history including details about seemingly unrelated conditions (for eg, psoriasis or bowel habit)
  • the actual physical examination including in areas apart from the knee involved
  • investigations such as blood tests and possibly, radiological examintions

I’d also advocate that the fluid in that joint be drained.

Synovial fluid (the joint fluid) is valuable. It can be sent to the lab and analysed. This will differentiate between mechanical/degenerative causes and inflammatory causes. It may actually help determine the actual cause of inflammatory arthritis as in the case with gout or pseudogout.

The point of this post is to remind people that we shouldn’t automatically treat all swollen knees as due to “wear and tear”.

This happens way too commonly.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Treat to Target: rheumatology reality or pie-in-the-sky?

11

20140317-050500.jpg

By Dr Irwin Lim

I’m lucky enough to be writing this from Prague. It’s around 4.30am and I am wide awake. Usual story with jetlag.

I’m attending an Immunology Summit here, with lots of the big guns in rheumatology presenting and sharing their perspective.

The overarching theme of the meeting is T2T.

Treat-to-target.

This is a concept well developed in Rheumatoid Arthritis. At the start of the disease, the rheumatologist involves the patient in a discussion about setting a target. Disease is then monitored regularly and the target measured. If the target has not been reached, the treatment is modified and usually intensified to reach the target.

Usually the target for the rheumatologist is a very low level of inflammation and some concept of remission. The target may be very different for the patient and more linked to symptoms and function. Some combination of both perspectives are aimed for.

By doing this, outcomes have been shown to be improved. Solid outcomes such as less joint damage, less loss of function and work, and improved quality of life.

At this meeting, the chairperson and steering committee were more provocative.

They extended this T2T concept to a range of other diseases we treat: Psoriatic Arthritis, Ankylosing Spondylitis & Spondyloarthritis, and Systemic Lupus Erythematosus (SLE).

Speakers framed their talks and discussions around this. Can outcomes be improved by treating to a target? What exactly is the target? How to we derive realistic ways to measure and document the target in diseases with protean ways to manifest themselves, meaning the symptoms and signs can differ between individuals and also differ between a specific individual at different timepoints.

Now, my disclosure is that I do believe, relatively strongly, in the T2T concept for Rheumatoid Arthritis. I want to believe in it for the other diseases but I do need to mull over it and we do need a more robust body of evidence.

There are plenty of skeptics, as to how T2T can be implemented in the “real world”. Here are some reasons why:

1) The problem with setting the target. This is not easy as already suggested above.

2) Measuring the target. The majority of rheumatologists do not perform composite disease measurements. The majority of rheumatologists do not use patient-reported outcome measures (apart from asking “How’re you doing?” or something similar). If you don’t measure and document, and rely on gestalt, it’s hard to implement T2T.

3) Seeing patients sufficiently regularly to implement the more frequent changes of treatment required to achieve the target. In active rheumatoid arthritis, patients should be seen 1-3 monthly. In locations where rheumatologist supply is an issue, or in very busy, resource-limited clinics, this is not viable and the time between clinic visits may be considerably longer. Also the time afforded to discussion to achieve a shared target is likely to be curtailed.

4) We still need long term data (except for rheumatoid arthritis I think) that more frequent treatment changes, and generally more intensive or potent treatment leads to more benefit than harm.

My bias is that the quicker and more completely one controls an underlying inflammatory disease, the better life will be for the patient, both short-term and in the very long-term.

I however appreciate there are caveats.

Share your thoughts?

AS frustrates, you & me!

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Courtesy of Photobucket/by mutantnoggins

Courtesy of Photobucket/by mutantnoggins

 

By Dr Irwin Lim, Rheumatologist

Ankylosing Spondylitis is such a frustrating disease. It’s under recognised and this then leads, to under diagnosis and often, inappropriate or inadequate treatment.

Why?

It’s not generally because people don’t seek treatment. It’s also not because health professionals don’t want to help.

  • It’s because it can be reasonably insidious in many. It’s a disease that can creep up on patients in some cases.
  • As it usually begins in early adult life, it’s so often blamed on something else. If you’re male, it must be sport or that lifting you did at work. It you’re female, it’s those pregnancies which caused it. It’s poor core stability…. It’s your poor posture….It’s how you have to sit for so long at work….
  • It may provide clues in areas remote from the spine. This gets treated by other unrelated health professionals and through lack of awareness or poor communication, the penny does not drop so 2 + 2 does not end up equalling 4. For eg, people with ankylosing spondylitis may get eye inflammation or they may have bowel inflammation or they may present with tennis elbow or heel pain….
  • Even if diagnosed, ankylosing spondylitis typically advances slowly over many years. Patients learn to cope and get on with life, and if they don’t attend regular follow-up with rheumatologists interested in the disease, this can lead to insidious decline in physical abilities and loss of function. For eg, Think of that slowly stiffening neck and the progressive difficulty with field of vision while driving…
  • Co-morbidities, such as osteoporosis usually develop silently. People don’t think about it so it’s not looked for or monitored.

The points I’ve listed above lead to late diagnosis or misdiagnosis. Patients often enter a merry-go-round seeing help from numerous chiropractors, physiotherapists, osteopaths, doctors etc, etc. They get frustrated and unfortunately, suffering is somewhat prolonged. Costs, including time and wasted opportunity, escalate.

It’s frustrating to all.

We need to keep working on improving awareness of this frustrating disease. Awareness among patients who suffer from chronic spinal pain. Awareness among the health professionals who may come into contact with various aspects of this disease.

BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.

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