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Living with Psoriatic Arthritis (PsA)

Does Methotrexate help PsA? Study says no. What do you think?

#1

This article says that Methotrexate does not help PsA. What do you think? I take it and now I’m going to ask my new rheumy about the efficacy.

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#2

I can only speak from my experience which is that it didn’t help me before side effects made it an unsuitable medication for me. However my husband’s aunt has been on it long term for her rheumatoid arthritis and it suits her perfectly and manages her condition well. Swings and roundabouts I guess…

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#3

Maybe it’s more helpful for RA than PsA?

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#5

Views differ. In ‘Psoriatic Arthritis (The Facts)’ by Dafna Gladman and Vinod Chandran, the conclusion is that doctors continue to use Mtx primarily because patients report that it helps them and that the jury is out with regard to prevention of radiographic changes.

There’s also its role in ‘backing up’ the biologics to consider …

I found that Mtx helped me a fair bit initially, when I took it on its own. The stiffness in my knees improved enough to get me walking, fatigue lessened also.

I’d like to read the article but looks like you have to join up to read it? However the title suggests that some with PsA are helped by Mtx. Does the article go on to contradict that?

I really wouldn’t want to rely on internet research alone to decide on the best medication to prevent my joints disintegrating. The stakes are too high. We folk with PsA desperately need good rheumies.

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#6

Hi Sybil,

Here’s what the article dated February 26, 2019, says:

Study Synopsis and Perspective:

“In a phase III, double-blind, randomized placebo-controlled trial, researchers found that treating early PsA with etanercept, a tumor necrosis factor-α (TNF-α) inhibitor, was more effective than treating with methotrexate, and that adding methotrexate to etanercept was minimally more effective than monotherapy with etanercept.”

This is new to me - that’s why I asked our wonderful PsA community for their thoughts.

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#7

The next thing besides biologics was the taking of methotrexate. The side effects were the problem on my end. Just reporting that my rheumatologist went to this drug just as fast as prescribing predinsone. Which kind of led me to believe that it was used in conjunction with a biologic. The liver enzyme elevation was a problem for me.

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#8

Well, the article does not really say that MTX does not help PsA. In fact, just over 50% of the people in the MTX only arm reached the target endpoint, which was a 20% or greater improvement in the American College of Rheumatologists criteria for improvement in Joint symptoms. Just over 60% of the people in the Enbrel only arm reached the same endpoint, pointing out that Enbrel seems to be a little better according to the criteria of the study.

There have been quite a few studies around for a while that suggest MTX has minimal effect radiographically for PsA (but does for RA). There were separate studies that showed that the biologics do have a positive radiographic effect. This study seems to support both types of those older studies. This one is probably news because it might be the first that has done a head-to-head between MTX and a biologic (note though, without a placebo arm, there is no way to tell whether MTX had a radiographic effect - all we know is that it wasn’t as good as Enbrel). Some of this is from memory way back when I was first diagnosed and was researching it, @tntlamb can correct me.

Many people, do find, however that MTX helps at least a bit with symptom control. And certainly, if you are also taking a biologic, in the vast majority of cases, taking MTX concurrently around halves the risk of developing antibodies to the biologic (which will end up in a fail of some sort, some of which can be truly horrible, as I can attest to). As far as I understand it, Enbrel is one of only a small number of exceptions to this antibody thing.

Finally, as my Rheumy, who is a big researcher said to me, we still do not understand how MTX works for arthritis, and for people who tolerate it, it really has no serious side effects. See the thing is, if we don’t know how it works, then by removing it, its possible we are removing a really positive effect on the PsA, but one that can’t be seen radiographically. After all, for many of us, our most quality-of-life altering symptoms can’t be seen on an x-ray.

Certainly, it does suggest that MTX only treatment is not be ideal for PsA, though I think most Rheumies are slowly (in Australia and the UK) coming around to that, if they have not already decided it for themselves (most in America).

Bottom line is, if it can be tolerated, it is doing something positive for most people that we still don’t understand, it doesn’t pose the sort of serious infection or neurological risks that the biologics can (though yes they are very rare), and it will halve the chances of developing antibodies whilst on biologics - this was pretty much the exact line my Rheumy gave me when I was asking whether it was really worth staying on MTX years ago. I could see his point, so I’m still on MTX.

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#9

I think @tntlamb once put up some info about how methotrexate works with certain biologics, and I’m almost positive he said pretty much what the article says…that Enbrel doesn’t work any better with methotrexate…something about the chemistry of Enbrel.

Sorry, I’m so unsure of exactly what tntlamb had posted, but I took notice at the time because I’m on Enbrel and I don’t take methotrexate, so I was relieved to know that.

The article is only about Enbrel and methotrexate, so those of you on a different biologic might benefit more from adding methotrexate.

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#10

This is a very poorly written article. It would not have passed muster were this a peer review Ed journal, but it’s no, Med the Today is one of the Internet Enquirer Blogs.

It is saying something that the study did not. Prescribing protocols from U of W, where this study was done for Enbrel have it as a monotherapy and MTX added as needed.

ACR 20 protocols BTW only cover a small Portion of PsA symptoms. I could present numerous studies that suggest the opposite.

All I know is that it works for me. I never miss if I do I can guarantee my left knee will feel like crap and a very annoying patch of P will show up in an unmentionable spot and between my toes. Than Good rhemies are trained to look beyond ACR20 or we would all be a lot worse off.

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#11

Thanks for your thoughts @tntlamb

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#12

Agree with that. Most of the old studies were all based on ACR20 if I recall and I could never understand why - nobody I know is going to get a 20% improvement and sit back and say “well gee, I’m happy with that, I think I’ll leave my meds as they are”. The gap between how good the biologics and MTX are gets bigger and bigger as the ACR raises. Lack of a placebo arm made the design a bit disappointing too, but maybe ethics?

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#13

Not sure why no placebo… Ethics for sure IMO. The author doesn’t understand numbers… she pulls these out of the study “the percentage of patients who received rescue therapy at or after week 24 was 24.3% on methotrexate, 16.2% in the etanercept cohort, and 12.7% in the combination treatment…” The meaning is pretty clear to anyone with basic stats course A quarter of those taking the Enbrel MTX combo had no flares requiring rescue therapy!!! (predi burst, injections etc) Thats HUGE. The answer the study was looking for was not is MTX worthless but rather should it be used along with Enbrel from the start of therapy or should it be added if Enbrel isn’t quite getting the job done? The conclusion? Its essentially 1 in four don’t The meaning? Its up to the doc not enough evidence to say yes or no. The only losers are those who misread this study, depend on the article and refuse MTX if offered AND the Manufacturer of Enbrel who touts it as monotherapy. Clearly its not.

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#14

Good points tntlamb!

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#15

Thank you everyone for taking the time to reply - much appreciated!

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#16

I’m using the biosimilar to enbrel Benepali as a monotherapy, but my rheumy is worried about it and is very closely monitoring me. That’s only because the sulfasalazine I was taking with it, had a hissy fit and made me have diarrhoea for 7 very long weeks landing me in hospital at the end of last year. Her thoughts are though out of the two, humira or enbrel, enbrel did better as a monotherapy. But only ‘did better’. And so far for me it’s working just fine as a monotherapy in fact I’d say it’s working extremely well. But it only around 3 months so far. You though @Grandma_J have had an excellent run of it as a monotherapy which gives me hope.

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#17

I took the oral and injection at different times within a few years of each other. It did not work for me.

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#18

@tntlamb , the article is a re-write of a peer reviewed original: https://onlinelibrary.wiley.com/doi/abs/10.1002/art.40851

As you point out, it doesn’t say that mtx doesn’t work, but that mtx doesn’t work any better than etanercept. Specifically, “Etanercept monotherapy and combination therapy showed greater efficacy than methotrexate monotherapy in ACR and MDA responses and radiographic progression. Overall, combining methotrexate and etanercept did not improve etanercept efficacy”.

It’s an interesting finding for me, because these are my meds (well, MTX + Benepali). I’m struggling on them, because although my joints do seem to be helped by Benepali, I have been run down, exhausted and a bit poorly since 2-3 months after starting Benepali. The two together seem too much for me, so I’d be glad if I could stop the MTX. I’ll discuss it with my rheumy team at my next appointment. Thanks for sharing :slight_smile:

(Hello everyone :slight_smile: Long time no see!)

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#19

Methotrexate did not work for me. I took it for five years an in reality did not find any difference. I have taken Otezla and am now on Taltz. I have a very stubborn case of PSA . We

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#20

I was on 20mg MTX for 2 years and it did nothing. It was in combination with first Humira then Stelara. I was in constant need of supplemental steroids (tabs and Methyl predictions infusions) On Otezla and Tremfya now with better results! haven’t needed steroids :slightly_smiling_face:

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#21

My Rheumatologist has me on methotrexate because he says it helps my medication, which is Remicade, work better. I have been on a good streak with minimal flare-ups over the last few years, so I am happy to continue taking it

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