nodules | Arthritis Information

I have nodules on both of my elbows. Very unattractive. The doctor said sometimes the MTX can actually cause nodules to form. Has anyone here ever heard of this?
Mary

Nana52,

I have nodules annd found this about mtx and nodules.

A Family Physician's Guide to Monitoring Methotrexate

KELLY W. JONES, PHARM.D.: McLeod Family Medicine Center, Florence, South Carolin
SUPEN R. PATEL, M.D.: Carolina Health Care, Florence, South Carolina

Methotrexate has a long history of use in the treatment of various immunologic diseases, including rheumatoid arthritis and psoriasis. Although the drug is usually prescribed by a subspecialist, a family physician may assume responsibility for monitoring methotrexate therapy. Major toxic effects, such as hepatic, pulmonary, renal and bone marrow abnormalities, require careful monitoring. Minor toxic effects, such as stomatitis, malaise, nausea, diarrhea, headaches and mild alopecia, are common but respond to folate supplementation. Methotrexate is administered once weekly as a single dose or in divided doses given over a 24-hour period. To reduce the incidence of major toxic effects, methotrexate should never be given in daily doses. Relative contraindications include renal dysfunction, liver disease, active infectious disease and excessive alcohol consumption. Both women and men of reproductive age should use birth control during methotrexate therapy. Potential drug interactions include salicylates and nonsteroidal anti-inflammatory drugs, which are both commonly used in patients with rheumatoid arthritis or psoriasis. A premethotrexate evaluation is important to ensure proper patient selection for this effective but potentially toxic drug. (Am Fam Physician 2000;62:1607-12,1614.)

Methotrexate is currently indicated for the treatment of acute lymphocytic leukemia, rheumatoid arthritis and psoriasis.

Methotrexate has an unusual history. What began as a drug for the treatment of cancer, particularly childhood leukemia, is now used to treat a wide variety of immunologic disorders.¹ The use of methotrexate in the treatment of psoriasis and rheumatoid arthritis dates from the 1960s.^1,2 From the late 1970s to the early 1980s, many rheumatologists were reporting their experiences with methotrexate use in studies of rheumatoid arthritis.² Guidelines for methotrexate use were then developed to address dosing, liver biopsy and monitoring strategies, which were aimed at reducing the incidence of adverse effects.² Currently, methotrexate is indicated for the treatment of acute lymphocytic leukemia (ALL), rheumatoid arthritis and psoriasis. However, the drug has also been found efficacious in the treatment of other diseases, including asthma, systemic lupus erythematosus, Crohn's disease, myositis, vasculitis and ectopic pregnancy.^3-5 Many physicians use methotrexate for its steroid-sparing properties in patients with asthma and others who may have side effects related to corticosteroid use.⁶ The key to the success of methotrexate in treating any of these diseases (with the exception of ALL) is the recognition that low-dose therapy achieves efficacy while minimizing side effects.

It is not uncommon for a family physician to monitor the efficacy and safety of methotrexate therapy in a patient receiving concurrent care from the subspecialist who prescribed the drug.

Minor and Major Toxic Effects

Methotrexate is a toxic medication, but if it is dosed correctly and monitored appropriately, its toxic effects can be minimized.⁷ These effects are categorized as minor or major.

Folate supplementation with 1 mg daily or 7 mg once weekly should be considered for all patients.

Minor toxic effects such as stomatitis, malaise, nausea, vomiting, diarrhea, headaches and mild alopecia are not life threatening but occur in 20 to 30 percent of patients. Other effects in this category include fatigue, mood alteration, dizziness, fever, myalgias and polyarthralgia. Most minor toxic effects are associated with depletion of folate. Folate supplementation with 1 mg daily or 7 mg once weekly should be considered for all patients.⁸ Studies show that low-dose folate does not interfere with the efficacy of methotrexate.⁹ Most rheumatologists advise patients to avoid taking the folate dose on the same day as the methotrexate dose. Often, minor toxic effects respond to a reduction in the methotrexate dose or an adjustment in the dosing schedule.

Rheumatoid nodules may also increase in size during methotrexate therapy, despite good control of the disease process.¹⁰

Major toxic effects of methotrexate, such as hepatic, renal, pulmonary and bone marrow disorders, occur less frequently than the minor effects but may be life threatening.⁷ (A methotrexate monitoring form is shown in Figure 1. It may be copied and used as part of the patient record for data collection and assessment.) Patients should be warned of the possible development of malignant hematologic diseases such as non-Hodgkin's lymphoma during therapy. The methotrexate package insert cites cases in which malignant lymphoma regressed after withdrawal of methotrexate without the need for antilymphoma treatment. Appropriate risk assessment is required to ensure selection of the proper candidate for methotrexate therapy.

I posted this in it's entirety because of the information some might find interesting and of good use.

LEV

Thanks for posting all of the info. Interesting to read.
Mary

Can you post pictures of your nodules Mary? Lately we've been sharing a lot of different pictures and the ones of different arthritis related things have been so informative. I'm sure everyone would get a lot out of it if you could post some.

No big deal if you can't; just thought it might be good if you could.

I had nodules on my left forearm, before my diagnosis and started taking MTX, which I understand is a major flag for RA - but I was told I was just depressed. Gawd. Anyway, they have actually gotten smaller after a year on MTX. I have a little nodule on my toe that's shrinking, I think because of the antibiotics I'm taking. I have nodules on my elbows but they're caused by psoratic arthritis. They come and go, never leaving any scarring or discomfort. They are painful when there. Lev, good post on MXT. LindyWell, I'll have to get my husband to take a picture of the nodules, then figure out how to post the photos here. I'll give it a try. Dirctions would be helpful.
Mary

Nsaids are contraindicated with MTX? Is that what I read? I was given prescriptions for MTX and Ibuprofen 800 MG, 3x a day.Hmm....