Gastritis, PPI’s and Methotrexate, a new chapter on the joys of PMR/GCA.

[Omakaat]

Hi all,

Just read something that, at least for me, cleared up a puzzle. Since November 2023 suddenly I experienced belly aches that would wake me up, 4-5 times at night. My specialist prescribed Pantoprazol, no effect. Then Omeprazol. Little effect, but at least some.

Anyway, in the last couple of months I began to suffer from extraordinary fatigue, and after some experimenting found out it was a side effect of MTX, which I have been on for years without any ill effect. So? How come?

In the mean time I switched to a new specialist, famous for treating GCA and specialized in the management of prednison. I asked if I could relinquish the MTX, she said I could just reduce it. Little less fatigued now, only two days in bed instead of three.

And today, being bored but forced to rest, I stumbled upon a line in a Dutch Farmaceutical Handbook: taking a PPI when on MTX will greatly enhance the side effects of MTX.

Really? I would have expected that at least one of the two specialists would have mentioned this.

Right, onwards to a new anti gastritis medicine. Famotidine, anyone with experience with that? Other helpful tips on gastritis while on prednisone?

Oma Kaat

[Grammy80]

I liked your post because....getting an answer is such a good thing~! It is a start. As a GCAer I've been on pred since 2019 and had a history of bleeding ulcers and a stomach bleed from Ibuprofen. I've been on one stomach med or another for 60 years. The most successful for me has been Carafate or generic sulcralfate. Each day I take two Pantaprozole and three sulcrafate. I don't believe it is readily available in the UK, but hopefully the Netherlands. Be well... 💞

[harpsichor in reply to Grammy80]

This probably explains why I felt so exhausted during the six months I injected methotrexate - I was taking two 15mg Lansoprazole every morning. I need to take it because, even before I had PMR I have had a hiatus hernia for many years, and the prednisolone made the heartburn worse. I wonder if the research being done by Dr Sarah Mackie on MTX use for PMR takes that into account? Certainly her rheumatologist colleague, by whom I am being treated, has never mentioned this interaction.

[Omakaat in reply to harpsichor]

And Harpsichord, what a intriguing name!, also thanks for your reply. Perhaps the reaction is so rare, it skips their rheumatologist mind? The gastritis is more or less shrugged of. Not their expertise, not their concern, moving on. And it is so annoying! Good thing PMR/GCA teaching us to be patient as well as to be tenacious.

[harpsichor in reply to Omakaat]

I think PMRPro has made a very good point further down about the amount of MTX needing to be much higher to provoke that sort of reaction …. But as to names, I meant to be Harpsichord with a d at the end because I like baroque music, but there was not room for the d! And does Omakaat mean Grandma Cat in Dutch?! (I used to live in Germany and Belgium)

[Grammy80 in reply to harpsichor]

harpsichor....we amaze....all of us on the forum. Your reference may be a good point to add to your list of questions. I go into my visits with a list while I am getting 'my 15 minutes of fame.' If I have notes in hand and ask to check my list...I get a few more minutes.💞

[Omakaat in reply to Grammy80]

Thank you, I will explore the sulcrafate fingers crossed!

[Omakaat in reply to Omakaat]

Sorry, above is ment to be a thank you for Grammy 80.

[PMRpro Ambassador in reply to Omakaat]

You have replied to her - it says in the box next to your name.

[PMRpro Ambassador]

Everyone is different and normally the exaccerbation of MTX side effects when taking a PPI is only seen in patients on the oncology doses of MTX which can be 10 or 20 times the dose used in rheumatology. It was discussed in a post in the last few months.

The side effects with MTX and pred is a similar story. MTX is used as it is thought to increase the antiinflammatory effect of pred - but what doesn't occur to the doctors is that it can also increase the other, adverse, effects of pred. When I started MTX I developed pred effects I had never had before, ravenous hunger, weight gain, worse bruising, and the overwhelming fatigue lasted until 12 hours or so before the next MTX dose was due. I ditched it!

And something else that isn't common knowledge is that the side effects don't always start immediately, sometimes it can be months or even years later.

[Omakaat]

Mentioned in an earlier post? I did try different words in the search field, nothing relevant came up. Good thing the Relevant posts is active again.

I do seem to recall reading that your experience with MTX did not exactly made you a big supporter 😉.

Side effects starting later: well definitely starting years later in my case. And on mainly on higher doses of MTX, that was not mentioned in the Farmaceutical handbook: interesting, food for thought.

Handbook did mention that nowadays it is almost exclusively used in rheumatology. It has a very limited range in chemotherapy and is becoming obsolete.

Since the Omeprazol does help, but not a lot, I will definitely go on a search for something else/additional, like the sulfacrate Grammy80 mentioned. At least it will keep me entertained while resting.

Thanks PMRPro, your reaction always make me think again, and is much appreciated.

[PMRpro Ambassador in reply to Omakaat]

It is certainly one of the most commonly used drugs in rheumatology but I think it is still used a fair bit in oncology in some countries, particularly second line as a tried and tested drug, My husband hated it - 30 years later even the mention made him feel sick.

[AtopicGuy]

The paper below suggests that the interaction between high-dose methotrexate and proton-pump inhibitors emerged about 12 to 15 years ago. It says:

"There is evidence to suggest that concomitant use of methotrexate (primarily at high doses) with PPIs such as omeprazole, esomeprazole, and pantoprazole may decrease methotrexate clearance, leading to elevated serum levels of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. In several case reports, no methotrexate toxicity was found when a histamine H2 blocker was substituted for a PPI. Based on the reviewed data, the FDA updated the methotrexate label to include the possible drug–drug interaction between high-dose methotrexate and PPIs. Physicians should be alerted to this potential drug–drug interaction in patients receiving concomitant high-dose methotrexate and PPIs."

ncbi.nlm.nih.gov/pmc/articl...