The strategic plan in treating RA has changed from a conventional process of using NSAIDs and corticosteroids to control symptoms, to a more biological modifying process by adding disease-modified anti-rheumatic drugs (DMARDs) to the preceding to alter the inflammatory process and prevent joint damage.  This is one of the milestones in the treatment of RA.

Since the mid-1980s, MTX has become the more popular treatment for RA because of its effectiveness and ability to work more rapidly than other DMARDs.  MTX is an anti-metabolite that interferes with the way cells utilize essential nutrients, which in this case is folic acid.  In addition to its ability to inhibit the activity of our immune system and reduce inflammation associated with RA and PSA, MTX can also slow the growth of cancer cells when prescribed in a different dose and schedule.  Therefore, the use of MTX in the treatment of RA is not regarded as a form of “chemotherapy”.

Depending on the patient, MTX can be taken as a pill by mouth or as an injection.  When taking the oral form, all the prescribed pills should be taken together, at the same time, or in two 12-hour intervals, on the same day, each week.  For those who cannot tolerate the pill form due to gastrointestinal problems, MTX can also be given as weekly injection, just beneath the skin.

Usually, MTX is started at 7.5 mg once a week, and is gradually increased as needed, up to a maximum of 25mg per week.  Because it takes up to four weeks to take effect, NSAIDs (non-steroidal anti-inflammatory drugs) or corticosteroids are usually continued to control symptoms. However, when the MTX kicks in, these medications may be decreased.  Although MTX and NSAIDs may interact with each other, they can be taken together.

Common side effects may include nausea, vomiting, loss of appetite, and mouth ulcers.  However, these side effects can decrease and even disappear with over time.  In order to reduce the incidence or severity of side effects, folic acid at 1mg daily except on the day you take MTX, can be very helpful.

One important side effect that should be closely monitored is the very rare complication of liver damage.  While taking MTX, liver functions should be monitored via blood tests, usually every two months, and it should not be taken while you are pregnant or breastfeeding.  Furthermore, because alcohol and MTX both have the potential to affect your liver, it is advised that alcohol consumption be reduced or even eliminated, except for a special occasion.

Since DMARDs often take from several weeks to several months to work, trying them requires patience, commitment, and time.  Once symptoms have subsided, patients may have to stay on DMARDs for a long period of time with decreasing the dosage overtime.  Although side effects may result from the use of DMARDs, severe ones are uncommon and are usually reversible once the drug is discontinued.  Frequent laboratory monitoring will largely keep side effects from occurring.

Other DMARDs such as Leflunomide and Sulfasalazine have similar safety profile but are not as effective as MTX.  Combining two or even three DMARDs is also effectiveness for patients with an inadequate response to MTX only.  Despite the powerfulness of DMARD drugs, only 40-50 percent of patients respond well to treatment.  Though they can slow down the progression of joint damage, the results are still unsatisfactory.

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