I have Rheumatoid Arthritis and I take hydroxy, methotrexate and abatacept
Last week I requested some more naproxen. I don't take a lot if it these days since I started with abatacept so it was a year or more since my last prescription request.
I was told 'there is a 3 star interaction with methotrexate, I think we have discussed this before' She later said it can increase plasma levels with methotrexate.
The gp then agreed to give me naproxen saying I seen to be in a steady state
Well, we haven't discussed it before and I haven't been told about this interaction before and I have no way of knowing from a short message via text whether I should be concerned or if they are just covering their backs.
I have had a pharmacist shriek hysterically at me that I shouldn't be taking naproxen with methotrexate. I was naturally rather taken aback and asked what I should take for my RA. The pharmacist then calmed right down, like she was a different person, and oh well if I had RA that was okay then! My rheumatologist (and another one who was sitting in with her) was firm last time I saw her two years ago that I can take naproxen and I can see from posts on here that other people have been prescribed it while on methotrexate recently.
My gp surgery has also previously said I should not be taking omeprazole with methotrexate. So I phoned the rheumatology helpline to ask what I should take instead. They told me flatly that I should be taking omeprazole when I am taking naproxen and refused to suggest an alternative, telling me to go back to the GP surgery and tell them that. The next time I asked for some omeprazole the surgery said no and offered me ranitidine instead, which I accepted as it was for a short course. I turned up at the pharmacist to pick it up and was handed some omeprazole after all....
Is anyone else being given conflicting advice and being told off by gps and pharmacists for asking for naproxen and omeprazole? It makes it very unpleasant when you feel rotten anyway and just want the pills the rheumatologist has told you to take.
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JenniferW
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How strange. I was taken off diclofenac by my new GP and prescribed naproxen instead and my rheumy ok’d this. I am also on mtx and lanzoprazole and have never been told by anyone not to take the combinations 🤷🏻♀️ How annoying that you have to go backwards and forwards between the three of them. I hope it’s sorted for the future now.
Hi Kitty, thanks for the info. Yes, I have always been told not to take dicoflenac. That's been from multiple sources and has been consistent advice. Yes, fingers crossed for the future.
I’ve taken both naproxen and omeprazole at the same time as mtx on a consultant’s recommendation; the concerns from other professionals is a case of a little knowledge sometimes being a dangerous thing, I think. I’m not knocking pharmacists or GPs, they are eminently qualified - far more so than me in a medical capacity - and have worked hard for those qualifications, but they’re not specialists, and just like a consultant neurologist probably wouldn’t have much clue when it comes to managing inflammatory arthritis, GPs and (some) pharmacists simply don’t know what they don’t know. That’s not to say consultants can’t get it wrong, so I would always listen to a pharmacist in particular that had concerns about drugs that have been prescribed, but if in doubt, other professionals should speak to the prescriber rather than messing us around with meds and leaving us to do all the chasing.
For future reference, the BNF is the publication all doctors in the UK use to correctly and safely prescribe medications, and it’s available online to anyone. It’s a really good resource covering usage, dosage, contraindications etc., and on every drug entry it will give you a link to a list of drugs known to potentially interact with it, tell you what the risk is, what the evidence for the risk is, and what the manufacturer recommends should be done. In the case of naproxen and mtx, the concern is potential kidney toxicity because both drugs are heavy on the kidneys, and it simply advises monitoring. Anyone on dmards and/or biologics usually has their bloods monitored fairly regularly in any event, including kidney function as standard. In the case of omeprazole, the concern is that it decreases mtx clearance, but only with reference to high dose mtx, and the doses used in RD are minuscule. Even with high dose mtx, though, the advice is use with caution or avoid, not that it’s an absolute no-no. The link to the BNF online is:
From experience, I’d ask for it in writing from rheum that you are to take these drugs at x dose alongside the mtx etc. Get them to send a copy directly to your GP and one to you, then if you have any issues you can refer the GP (or even the receptionist, as I’ve had them be the one to refuse prescription requests for similar reasons before) to the letter, and take your copy along to the pharmacy to show them if/when necessary. This is also one of the reasons I’ve long stuck to using a small, independent pharmacy; they get to know us really well, so as long as it’s safe, don’t question (or ‘correct’!!) drugs sometimes being used in an unconventional manner. I generally have less issues, but my daughter’s script has caused no end of faff in the past because she’s on 15 meds a day and was using several drugs at adult doses from being a fairly young child. The condition she has means that she doesn’t absorb medication in the same way others would, so with the exception of painkillers, high doses of many meds are standard from birth. The letter from her specialists tack was the way I went in the end for several meds we were having problems with locally, not least daily antihistamines at up to 4 times the adult dose when she turned 10, and although pharmacy do occasionally change the labelling to what the instruction ‘should’ be on autopilot, i.e. take certain drugs in the evening when she takes them in the morning, they no longer mess with the combinations or dosages.
Yup, there’s the ideal world where we avoid all possible drug interactions. And then there’s life with a chronic disease where you have to make compromises and balance risks against quality of life.
As you say we are well monitored, which pharmacists and GPs forget.
That's really helpful, thank you. It explains why the pharmacist was so against naproxen and then changed her mind as soon as I said I had RA, it wasn't the condition, it was the fact that it meant my Methotrexate dosage would therefore be low.
I will pre-empt questions from my GP with a reminder that my dose is low in future and then ask for a letter from rheumatology if they continue to be reluctant.
Thanks very much for the link, I will have a read.
Gosh , your poor daughter on all those meds, she has my sympathy.
Ranitidine is no longer available its Cimitidine now and that may explain one thing but I'm sorry I don't know about anything else. I take Azathyoprine and Abatercept but asked to stop the Cimitidine as it's vile. And they said just take the AZA with food it's fine. And while research is a good thing nothing replaces an informed medical opinion. As for Omeprazole it is not harmless and should be used with caution and care so perhaps the Pharmacist was just being cautious which in itself is no bad thing.
Oh yes, I am happy that the pharmacist and gps are keeping up to date and looking out for me, it's just the lack of consistency.As far as omeprazole goes, I just take it for a few days at a time, so that should be okay. I think it's longer term use that causes some quite serious problems.
Definitely agree about the omeprazole. I certainly wouldn’t take it!!
I had issues with ranitidine and naproxen. I now don’t take either and feel loads better! On amitriptyline (pain) and omeprazole (stomach protection). Ranitidine was recalled in the USA, so swopped when there were supply issues.
I didn't know about the recall, that looks potentially quite serious. I will stick with the omeprazole. The naproxen does upset my stomach if I am not careful to eat it with a solid meal and I don't take it for any longer than I have too. I used to have to take it a lot, but fortunately abatacept improved things hugely.
It might not be conflicting advice…..pharmacists might not know the disease you are being treated for…..unless you are a regular patient & discuss your disease with them.Some drug combinations are OK for one disease, but not another.
I.m interested to know that were offered Ranitidine though….how long ago was that?
It has been unavailable for about the last couple of years.. ..maybe it’s now prescription only….it used to be an OTC drug.
The same pharmacist had just handed me a prescription for methotrexate, but she clearly hadn't looked at the dosage :)The ranitidine was a couple of months ago, but it had turned into omeprazole when I picked it up, so maybe the doctors had a discussion between them. They are a good practice in that way, they are very good in a lot of ways.
I can't keep track of ranitidine, you are right, it was Prescription only, them OTC, then not, now not all by the sound of it.
“It has been discontinued as a precaution because it may contain a small amount of an impurity that has been linked to an increased risk of cancer in animals. It's not yet known whether it will be available again in future. Ranitidine is a medicine that reduces the amount of acid your stomach makes.”
So now we know..but it really worked for me….& I though I had found gold when I was unpacking after my recent move..I found three unopened boxes of it!
I’ll take my chances (I’m not in any NSAID’s) on getting animal cancer! I only take it when I eat all the wrong things…& I’m not keen on omeprazole or lansoprazole”!
The thing I liked about it, was it got rid of my symptoms in a couple of hours with no nasty after effects…any similar meds leave me feeling nauseous for days..but I guess without Ranitidine I leave the rubbish food alone!
I think the confusion here is re the MTX dosage. It can be used as a chemotherapy drug at much higher doses, where obviously increase in plasma levels would be a concern. I had a recent discussion with my GP as my respiratory specialist changed my ppi to Esomeprazole as have lung damage from aspirating acid. Gp refused to renew prescription as it interacted with my clopidogrel which I take, after having a massive stroke at 52. She said it increased my risk of stroke. Then she decided to prescribe pantoprazole but stopped saying it increased mtx plasma levels. When I suggested this was more of a concern on high doses rather than rheumatology doses she agreed and prescribed. She checked with respiratory who confirmed at the dosage I take,25mg it was fine. The way I see it may actually improve the effect from MTX 🤪🤞
Hi Piggy, yes I've read the side effects, I just take it for a few days at a time when a bad flare up drives me to the naproxen. It doesn't sound like it's a good idea for long term use or even medium.Gosh that's a lot of cocodamol! Three days was enough for me, very effective, but not very nice side effects (constipation). I checked with the doctor about addictiveness and he said that people in pain don't get addicted very often, they can stop when the pain stops. And he said the side effects would make me stop sooner...
Hi JenniferYes I agree. I no longer take anything like 100 Co Codamol but it does still amaze me that it’s still on my prescription at that level. Yes you’re right about the constipation but with pre and probiotics suggested by my consultant, it’s no longer much of a problem.
I take methotrexate along with lansoprazole and naproxen. When I first started methotrexate I read the leaflet and saw the information that you should avoid PPI and naproxen and other similar pain killers. As a result I asked my rheumatologist but they said it was fine and to continue. It worries me about differing opinions and makes you wonder if what to trust.
I'm on MTX, have been for 13 years & have had 5 or 6 different NSAIDs in that time, including naproxen but currently etoricoxib. In all that time, in fact since diagnosis inn 2008, I’ve been prescribed omeprazole because I've always had an NSAID! I've had 20mg once a day but for a while now twice, so 40mg taken as 1 in the morning & 1 in the evening.
It's a matter of needs must rather than keeping to the letter of the law. We need these meds as part of our armoury & whilst there may be guidelines as long as we, as individuals, aren’t harmed by them then they'll continued to be prescribed concomitantly. As it is we are monitored on MTX so any issues should be picked up on promptly.
If your GP won't accept your word then I'm afraid the only option is for you to call your Rheumatology helpline again & ask that they write/email him/her & express their concern when it's a direct request from your Rheumy & that they to be added to your repeats list. It shouldn’t be necessary but then if they're not understanding of Rheumatology & commonly prescribed meds then it needs explaining so they do.
When I was first prescribed Mthx, I mentioned to my Rheumatologist that I’d read there was an interaction with Omeprazol, which at the time I was taking 20mg morning and 20mg evening. She said oh no, it’ll be fine. But within 6 weeks my liver tests had gone up to over 100!!! She kept reducing my Mthx until I settled on 10mg, which was fine for 3 years. Since having 2 bad flares last year, I spoke to my GP and went onto Lansaprozal only one dose a day (15mg) and lo and behold my liver tests are now completely fine 🙏 and my Mthx is back to 20mg.So for me, there was an interaction which affected my liver.
I haven’t been offered Naproxen for years, but I do take Nurofen for my rotator cuff pain.
thanks for letting me know your experience. It's a good reminder of how important regular blood tests are. I am sorry to hear you had such a bad experience.
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