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MTX Route Switch

MTX Route Switch

Hi,

I am going to do 1st MTX injection on Friday and hoping that may be enough to turn things round. ( same dose 20mg )

My question is has anyone experienced real improvement just from the switch from oral to injectable MTX ?

After many months of nothing happening I had a video conference with my rheumatologist today and he is suggesting throwing in sulphasalazine as well

" sooner rather than later ".

He says it's up to me when I want to begin this and my feeling is to wait a couple of months and see whether the injections are going to turn things round on their own before embarking on something else but that's based on the idea that the less drugs the better ... maybe this idea has to go out the window with RA although I am very attached to it.

It also seems that the more different things you are taking the more impossible it becomes to know where any effects , good or bad , are coming from...

My GP says I am overthinking things.

But anyway it would be great to hear anything on this.

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Hi I've been on the methatrexate injections for 6 weeks and still waiting for something to happen . I couldn't have the tablets as they made me so ill , so switched as the injections bypass your stomach . Definitely less side effects so that's a plus . Just hope and wait with 🤞 fingers crossed.... good luck 👍

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Thanks for your reply. There's a lot of hoping and waiting for me too. Sounds like you are at least half way to knowing something so good luck to you as well

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Well Rosey, I changed to injections after a year on tablets at 15mg. That was 8 years ago. It wasn't because of the most frequent side effects rather I needed an increase to 20mg & that sent my liver values too high. The starting dose was reduced to 15mg & this worked fine for a while. It was then my dose was increased to 20mg again, the same happened but as I responded well otherwise my Consultant suggested reducing to 17.5mg which worked fine for both the RD & my liver. Fast forward around 3 years & disease activity in my feet, my new Rheumy wants to increase my MTX to 20mg. I told her about my previous experience but she wanted me to try nevertheless so I did & the same happened, my liver values rose so back down to 17.5mg I came. I wasn't doing awfully well so saw a Registrar who added sulfasalazine. Long story short I had to come off that & also the leflunomide which replaced the SSZ. I'm still on 17.5mg & halted tapering the steroids so I'm just on those & the MTX at present for my RD.

I think your idea of trying out the injections first before starting double therapy is a sensible one. More from the point of as you're going to start them on the same dose as your tablets it may be just enough to keep you controlled & you may hold off needing another DMARD adding for the time being. Your idea it's a good one though, if you're unfortunate enough to have any side effect you won't be able to easily determine which is causing them.

You know that by injecting there's greater bioavailability? Because tablets go through the GI system some of the dose is lost, not so with injections as the med goes straight into the blood stream. At the higher end of DMARD doses (17.5 - 20%) there's a difference in efficacy of around 13.5% of the same dose, tablets vs injections is the norm, or around one tablet dose of 2.5mg. As you'd expect it's slightly more in higher doses up to 30mg.

I inject in my tum, alternate sides each week. A tip... when you receive your first boxes of injections just write L or R on the box, then you don't have to think what side you'd injected the previous week.

I do hope you find changing suits you, it does many who's symptoms are disruptive or who don't respond well to tablets.

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Hi. thanks NMH for your reply. Does your rheumy suggest biologics? Mine has begun talking about that being the next step if this doesn't work. It sounds as though you are managing now on the minimum although I suppose the steroids make a big difference. Mine says he is reluctant to prescribe them but is ok with the occasional IM shot.

It's good that you think it sounds sensible to wait and see, with the bioavailability increase injections will bring. I have just been given an IM steroid shot, today, so that will be a very welcome few weeks of rest from the pain and swelling in midwinter and to be able to move around more will be great. So I could wait until this wears off and see if anything has changed before embarking on the SSZ.

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Nope, not once mentioned it. As I said at my last appointment we decided I'd stop the steroid taper, this was the same time as stopping the LEF, she said we'd look at restarting the taper at my next appointment in May. I suppose it depends on how I fare once I've completed the taper but past experience has been that I've gone into flare so had to start them again which I don't want to do this time. You see I've been on them coming up to 5 years so want off them altogether but it depends on how MTX does on it's own, if as before I go into flare, especially considering I can't increase the dose & I've tried 3 other DMARDs not including MTX, I think that part of qualifying for biologics is sorted!

I'm hopeful you'll find you do better on injections, many do. The steroid injection will see you right through Christmas into the new year so that's good. I'm pleased you're considering the wait & see option, see how things go, see how you respond & until after the steroid wears off before considering starting SSZ, with luck on your side you may not need it.

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I agree wth you...in 18 years I never took more than one Dmard at a time. I just felt & still do, that if one doesn't work, OK try another one, not another as well as the one that is causing problems! Luckily my liver didn't revolt at Mtx.

At first I did try Prednisolone with Sulphasalazine with very scary side effects, so ever after it was one drug at a time. Luckily my rheumy went along with me & after failing on about 5 Dmards I started Rituximab only infusions in 2016, & so far so good.

I do think we can overthink all the drugs that are suggested we take.....but I feel I needed to go the one drug at a time way...but I do only have Sero+ RA, with no other condition.

Whatever you decide, I hope it's successful.

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Thank you for your reply AgedCrone.

It's encouraging.

It hadn't occurred to me to ask for one Dmard at a time and it's interesting that you managed to hold out for it. It sounds good, to me, to see what is happening thoroughly with one drug before confusing everything with another.

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