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Benefits of methotrexate defended at meeting
The bad reputation of methotrexate as a therapy in rheumatological conditions is unfair and inaccurate, a session at the Irish Society for Rheumatology (ISR) Spring Meeting heard.
Dr Donncha O’Gradaigh, Consultant Rheumatologist, University Hospital Waterford, outlined the benefits and risks of methotrexate, as well as the fear among patients and the difficulties around disclosing the risks to patients accurately.
There is a level of fear around the prescribing methotrexate and patients do not like it. This is unsurprising, given its toxicity at higher doses and in the treatment of cancer but the low doses used in rheumatoid diseases mean it is generally very safe and effective, Dr O’Gradaigh and other delegates who joined in the discussion contended. One delegate maintained that if patients were informed about the rare but serious risks of taking methotrexate, they should also equally be informed of the risks of not taking it, particular to their diagnosis.
Dr Donncha O’Gradaigh, Consultant Rheumatologist, University Hospital Waterford (third speaker)
Dr O’Gradaigh expressed support for shared decision-making and noted the risk of infection or death is not mentioned in various international guidelines on methotrexate usage risks. There is now a new national clinical guideline in development on the use of methotrexate, Dr O’Gradaigh said.
“Again the question arises, are we offering accurate information, are we able to provide accurate information and do we need to make that statement about methotrexate? Do we need to make it about all of our treatment options? Are we in a position to state one treatment option is more safe than another? Essentially, are we able to stand over our shared decision-making principles or do we need the sort of documentation we are producing?” Dr O’Gradaigh pondered.
A number of contributions from the floor mentioned that research has now found that there is not an increased risk of infectious lung disease from methotrexate in RA patients.
Speaking during the Q&A session, ISR President Prof David Kane said methotrexate is a very effective and safe drug “but the biggest problem we have is the fear regarding methotrexate that is out there in the community. Patients, pharmacists, professional colleagues that make the most ridiculous statements… ”
Speaking to the Medical Independent (MI) after the session, Prof Kane said it has been shown that far more patients develop serious side-effects from anti-inflammatories and steroids, which are now not used as much because of the effectiveness of biologics and methotrexate.
“There is a fantastic new review article in the Annals of Rheumatology, showing that patients who were treated with methotrexate had a good treatment response that is longer and do better than patients who are not treated with methotrexate. That’s the bottom line. We give methotrexate to make people better.
“Yes, the drugs have toxicity and methotrexate has always had a toxic identity because it is used in an extremely high dose in cancer, where it is toxic. It has a low toxicity in rheumatoid. Yes, random, scary, toxic events happen but overall, the patients who take methotrexate do so much better.”
Pain is the key topic at ISR Spring Meeting
Pain, its various manifestations and the best medical and non-pharmacological approaches to treating it were the key themes of this year’s ISR Spring Meeting, held in Kilkenny on 27 March.
Speaking to this newspaper, ISR President Prof David Kane said the high-quality speakers from a range of disciplines — medical, psychological, alternative and scientific — covered the full spectrum on pain knowledge and offered excellent learning points for delegates.
“I think rheumatology is a holistic, multidisciplinary discipline; that’s what attracts people to the speciality. We do have high-technology therapies and procedures like ultrasound, but at the centre of it is the holistic approach to patients. Yes, we’ve made huge advancements in the inflammatory diseases. They’ve gone from incurable to extremely well treated, if not curable, with certain kinds of drugs. But there are many more people out there with degenerative conditions. We hope stem cell therapies and things like that down the line will help people.
Prof David Kane, President, ISR
“We’re also hoping to find new types of pain relief. With scientific research, we are learning more about what causes chronic pain and can find new targets and ways of treating it. What was really interesting about the programme today was looking at non-drug-based therapies and how it has been shown they can produce biological effects. That is important because if you are promoting a multidisciplinary approach, people say ‘but yeah, it is the drugs that have a biological mechanism’ but here we can see non-pharmacological therapies can produce similar effects.”
Speaking about the setting-up of the RA registry by the ISR, Prof Kane said: “I think only when we have this data on practices and outcomes can we push for better funding for patients — that’s what it is all about.”
“In order to see how widespread [dose tapering] practices are and how effective they are, we need the registry. The hope for the future would be moving towards an electronic patient record so we would be not just managing our patients, but collecting this data at the same time.”
Acknowledging the HSE’s extremely slow progress in rolling-out unique patient identifiers and electronic records, he said the ISR is keen to design its own patient record template and present it to the Executive.
Prof Kane confirmed biologics would be incorporated into the RA registry.
“They represent the next step in the biologics story… It will be a big change. There are quite a lot of biosimilars coming out. We need to properly see how they work in our patients before we can really understand how similar they are. But I think they are going to give us more treatment opportunities. They will bring down costs but we are going to see a reduction in cost anyway as drugs come off patent. And hopefully that saving will be pumped back in rheumatology services,” he told MI.
Prof Kane also highlighted the success of rheumatology in treating AS patients.
“AS was a disease that was previously untreatable and now it is almost curable. It is fantastic. Those clinics went from heartsink clinics, to clinics where you have much happier patients whose disease is very well treated; they are functional.”
New psoriatic arthritis outcomes website highlighted at meeting
A new Irish website that is measuring outcomes in psoriatic arthritis (PsA) should be very useful for rheumatologists, the ISR Spring Meeting heard.
As psoriatic arthritis is a heterogeneous disease that includes features of peripheral arthritis, spondylitis, dactylitis, enthesitis as well as extra-articular manifestations such as skin and nail disease, it has a significant impact on patient function and quality of life. Assessment of all aspects of disease activity is an integral part of disease management, hence the rationale behind the setting up of the website www.mopsa.ie, based out of St James’s Hospital in Dublin.
Measuring Outcome in PsA (MOPSA) provides patients and clinicians with web-based access to the key instruments required in assessing PsA patients.
MOPSA consists of two integrated sections, one to be filled out by patients at, or just prior to, clinic visit, and the other section to be filled out by healthcare professionals (including rheumatologists).
Once the relevant data is entered, MOPSA will automatically calculate the patient’s and health professional’s scores, including chosen composite score. MOPSA will also inform the user if their patient meets the minimal disease activity criteria.
MOPSA can be simply used as a routine clinical tool for assessment of PsA patients, or it can also be used in a clinical study setting, where specific study sign-up will be required.
ISR relaunches Bernard Connor Medal for undergraduates
The ISR launched a new ISR Bernard Connor Medal for Undergraduates during its 2015 Spring Meeting in Kilkenny.
The Society previously ran a Bernard Connor Innovation Bursary to recognise and celebrate pioneering work in rheumatology.
The new Bernard Connor Medal has been established to encourage medical students’ participation in rheumatology during their undergraduate education.
The award is open to all students of medicine in Ireland and to Irish students studying medicine abroad. In addition to receiving the medal, the winner will be invited to attend the Annual Scientific Meeting of the ISR to present their work to the membership. At the discretion of the judging panel, up to two runners up may be awarded a commendation and full registration to attend the ISR Annual Scientific Meeting. Submissions may consist of a piece of original research, an essay on a clinical or scientific topic, a reflective essay on medical student experiences in rheumatology or an interesting case report. For the inaugural award, the ISR has chosen the theme of ‘Medical Student Observations in Rheumatology’.
Dr Connor is famous for being first to describe AS. Born in Kerry in 1666, he went to France at the age of 20 to study medicine, graduating in 1693. He set up in practice in Paris but subsequently became personal physician to King John III of Poland. Dr Connor regularly toured Europe, visiting medical centres of excellence in countries including Italy, Germany, Austria and the Low Countries.
He wrote the first clinical description of AS ever published in 1693. Dr Connor was elected Fellow of the Royal Society, a Fellow of the Royal College of Physicians and Membre de l’Académie Française, a remarkable achievement for a doctor barely in his 30s. He became ill with fever in October 1698, possibly of malaria, and died in London aged just 32.