General Medication Questions: Part 3
[continued from part 2]
One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.
Is Celebrex Linked to Swelling?
Pain Free on Antibiotics
Caffeine's Effects on Methotrexate
When Pain Relievers Cause Headaches
Are Generics Less Potent?
Vegetable-Based Glucosamine
Mix Butcher's Broom with Meds?
Testing for Medication-Related Liver Problems
Safer NSAID Alternatives
Methotrexate, Hormones and Hair Loss
Does Methotrexate Stop Working?
A Time Limit for Tylenol?
When Pain Relievers Cause Stomach Pain
Prednisone Withdrawal
Long-Term Antibiotic Safety
When NSAIDs Cause Swelling
Is Combining Drugs Safe?
How Can I Get Butazolidin
Long-Term Methotrexate Safety
Arava and Malignancies
Is Celebrex Linked to Swelling?
Q: I took Celebrex for five years but recently stopped. Three years ago, I developed lymphedema in my right foot, ankle and lower leg that is still bothersome. Could the medication have caused it? Can I reverse it?
A: Celebrex should not cause lymphedema, which is swelling of an arm or leg caused by a disturbance in the lymphatic system.
A variety of conditions cause lymphedema, including surgical removal of lymph nodes, blocked lymph ducts or, rarely, a parasitic infestation of the lymphatic system.
It is possible, however, for Celebrex to cause a condition with a similar-sounding name – edema. Edema is swelling, usually of the lower legs and feet, that occurs when too much of the clear fluid in the blood builds up when it is not excreted due to the effects of medications or conditions of the heart, liver or kidneys.
If the heart is unable to pump blood efficiently – a condition called congestive heart failure – excess fluid accumulates in the body and eventually seeps into tissues.
Treatment of lymphedema and edema involves increasing drainage of fluid from the extremities with exercise, massage or compression stockings. Depending on the cause, treatment may involve diuretics to help you eliminate excess fluid.
Stopping Celebrex could help decrease the excess fluid in the body, if you have edema. But if you have lymphedema, a work-up is needed to determine what is going on in your lymphatic system.
David Pisetsky, MD, Rheumatologist
Q: I have osteoarthritis (OA) and have taken nonsteroidal anti-inflammatory drugs (NSAIDs) as well as glucosamine, chondroitin and methylsulfonylmethane (MSM), all without much relief. I received penicillin as a preventive before surgery and was pain free on it. Can this be explained?
A: It’s great that you had some much-needed relief from your OA while you were taking penicillin. Although I can’t explain why you experienced relief, I can offer a few possibilities.
During the natural course of any form of arthritis, OA included, there are periods of both increased and decreased pain, stiffness and inflammation. When people do something different before a period of increased or decreased pain, they tend to associate what they did with the change. The improvement you experienced may have been completely coincidental and may have occurred regardless of whether you were taking penicillin – or any drug.
Another possible explanation is the placebo effect. If a person expects – even unconsciously – that something will produce a certain result, they are more likely to experience that result. Maybe something led you to believe that the penicillin might help, so it did. Although this possibility may sound silly, the placebo effect can be very strong. It is the reason clinical trials are blinded – that is, the participants cannot know whether they are taking the drug being studied – because the very knowledge (or belief) that one is taking a certain drug can produce a strong physiologic effect.
Least likely is that penicillin truly did have a positive physiologic effect on your arthritis, by reducing low-grade inflammation. There is published evidence that certain antibiotics may have an effect on certain forms of arthritis or related conditions, such as minocycline (Minocin) for RA and trimethoprim/sulfamethoxazole (Bactrim) for Wegener’s granulomatosis. But to my knowledge there is little to no evidence that this is the case with penicillin and OA.
John H. Stone, MD, Rheumatologist
Caffeine's Effects on Methotrexate
Q: I take 10 milligrams (mg) methotrexate once a week. I read recently that caffeine interferes with methotrexate. Is it OK for me to drink coffee?
A: Methotrexate works, in part, by increasing the amount of an anti-inflammatory chemical called adenosine in inflamed areas. Caffeine blocks the effects of adenosine. Results of studies have been mixed. In one study, 39 people with rheumatoid arthritis (RA) who had just started taking methotrexate kept a diet diary for three months. Those who consumed more than 180 milligrams (mg) caffeine (equal to 3 cups of instant coffee or 1.5 cups of brewed coffee) per day had a slightly weaker response to methotrexate than those with low intake (less than 120 mg per day).
But a similar study of 264 patients taking an average dose of 16 mg methotrexate per week found those who consumed an average daily intake of 211 mg caffeine had neither a lower response to methotrexate nor a higher disease activity. The studies did not take into account how much caffeine was consumed on days methotrexate was taken. It is probably a good idea to avoid large amounts of coffee, tea or other caffeinated beverages if you are taking methotrexate, but I see no reason to worry about occasional use. Remember that some over-the-counter pain medications also contain caffeine.
Don Miller, PharmD, Pharmacist
When Pain Relievers Cause Headaches
Q: I have OA of the spine. I have frequent headaches and wonder if they could be related to my arthritis. If so, what can I do? Regular pain relievers don’t help.
A: Occasionally headaches can occur as a result of osteoarthritis (OA) high in the neck where the spine meets the skull, but that is unusual.
Because you say pain relievers do not help, I suspect you may be experiencing rebound headaches, also called medication-overuse or toxic headaches. Taking pain relievers or other headache medications (such as those prescribed for migraine headaches) too frequently can create a negative cycle. For example, the labels on some pain relievers say to use the medication for no more than 10 days; if you use them longer, your body may become accustomed to them. Then, when you do stop, your body goes through a form of withdrawal. You experience headaches, much like the ones that occur when some people don’t get their morning caffeine. That spurs you to take more pain-relief medicine, worsening the problem.
If rebound headaches aren’t your problem and over-the-counter (OTC) analgesic medications, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin) or naproxen (Aleve), don’t help, I suggest you see a physician and ask for a different type of medication, as there are many types. For example, an antidepressant, taken on a daily basis, may help prevent headaches without causing rebound headaches.
Also discuss with your physician the possibility that you may have a more diffuse pain syndrome, such as fibromyalgia. People with fibromyalgia often have pain in the spine as well as headaches that don’t respond to typical pain relievers. If your doctor does diagnose fibromyalgia, a treatment plan of exercise, analgesic medications and perhaps antidepressants to improve deep sleep can help relieve your headaches as well as the pain in your spine.
Daniel Clauw, MD. Rheumatologist
Q: I have heard that generic drug makers are permitted to make their drugs to a potency of only 80 percent of the effective dosage. Is this true?
A: Generic and branded drugs both must meet the same federal standard for the amount of medication present in a tablet or capsule. The standard depends on the specific drug, but usually a leeway of five percent to 10 percent is allowed. For example, all naproxen (Naprosyn) tablets must contain 90 to 110 percent of the labeled amount, regardless of the manufacturer or brand.
The Food and Drug Administration (FDA) Office of Generic Drugs has conducted two surveys to assess differences between generic and brand-name drugs. The first survey, conducted in 1987, examined a large group of absorption equivalence studies and found that, on average, generic drugs differed from brand-name drugs by no more than 3.5 percent. In 1997 a second survey found an average difference of no more than 4.3 percent.
The primary goal in the generic drug approval process is to protect the public against drugs that are not equivalent to brand-name equivalents. For a generic drug to be approved, the drug must undergo testing to prove that its absorption by the body is equivalent to the original brand name drug. Under current law, a generic drug must possess three characteristics that fall within 80 percent to 125 percent of the original drug: total drug absorbed, maximum drug concentration in blood and time of peak blood concentration. At first glance there would appear to be a large potential for variation between generic and brand-name drugs; however, because all three parameters must fall within the specified range, the generic drug is almost always nearly identical to the brand-name drug.
There are very few drugs for which a generic equivalent has not been established. One is levothyroxine (Synthroid) – a thyroid hormone replacement used to treat hypothyroidism (underactive thyroid) and goiter (enlargement of the thyroid gland). That does not mean that the brand is better than the generic, just that the brand and generic do not have an established equivalence. The difficulty in establishing equivalence may be that the original is formulated so uniquely that it’s hard to duplicate, or that the drug is normally absorbed so erratically that equivalence is hard to establish.
The FDA publishes a book commonly known as the “Orange Book,” which lists products that are generically equivalent and those that are not. You can search the Orange Book online at www. fda.gov/cder/ob.
Don Miller, PharmD, Pharmacist
Q: I am allergic to shellfish, and glucosamine is made from shellfish. Are there any effective glucosamine products made from vegetables?
A: There are a few vegetable-based glucosamine products on the market. Some are made from corn, such as Deva Vegan Glucosamine, and some are made from fermented plant products, such as Regenasure glucosamine hydrochloride (HCl). Both are marketed to vegetarians and people, like you, with shellfish allergies.
Although vegetable-based and shellfish-based glucosamine products have not been compared head-to-head, you should try the vegetable-based product if you have OA and have had difficulty with the shellfish-based product. I usually recommend my patients take 1,000 milligrams (mg) twice a day for eight to 12 weeks and then decrease to a maintenance dose of 750 mg twice a day indefinitely.
Give the vegetable-based product a try. If your arthritis is severe or if you don’t get relief from it, pain medications or total joint replacement may be your next best options.
James McKoy, MD, Rheumatologist
Mix Butcher’s Broom with Meds?
Q: I’m considering taking an herb called butcher’s broom (Ruscus aculeatus) because it may help arthritis and circulation. I also take allopurinol (Zyloprim), furosemide (Lasix), levothyroxine (Levoxyl), pravastatin (Pravachol), potassium chloride and triamterene (Dyrenium). Are there any reasons I shouldn’t try it?
A: Butcher’s broom (also known as box holly and sweet broom) hasn’t been well studied scientifically, but it is generally touted as being useful for varicose veins, leg edema (swelling from fluid), hemorrhoids, gallstones and arthritis. Butcher’s broom is known to contain steroid-type compounds that have anti-inflammatory properties, constrict veins, increase lymphatic flow, and reduce edema by a diuretic action. I could find no human studies of its effectiveness for arthritis.
Some side effects that have been associated with it include anxiety, increased heart rate, nausea and stomach pain, and it may also increase blood pressure. There have been no studies on how it interacts with other medications.
I would discourage you from trying it, because there are so few good studies on the effectiveness of butcher’s broom, its long-term safety or how it interacts with other medications you are taking. Any substance – herb or drug, natural or synthetic – that is strong enough to help some medical conditions also has the potential for side effects and drug interactions. I encourage you to stick with treatments that are known to be effective and safe.
Don Miller, PharmD, Pharmacist
Testing for Medication-Related Liver Problems
Q: I am taking methotrexate, which I’ve heard can cause liver problems. How will I know if I am developing them?
A: You won’t know a liver problem is developing – at least not on your own. There are no symptoms, such as pain. The best way to tell if a problem exists is to have regular blood tests that monitor liver function. The disease-modifying anti-rheumatic drug (DMARD) methotrexate is used widely for RA, psoriasis, lupus and leukemia, but it can be toxic to the liver. Although side effects, such as liver cirrhosis (scarring), are rare, they can be serious, so everyone taking methotrexate needs to have regular liver function tests (LFTs).
Before starting methotrexate, one week after the first dose and then approximately every four to eight weeks after beginning the medication, you should undergo LFTs. These tests make sure the liver is working correctly by measuring certain proteins, such as serum albumin, and enzymes, such as aminotransferases, which are used by or created by the liver. If the results are abnormal, then the methotrexate dose should be reduced and the blood tests repeated in two to four weeks. Abnormalities of LFTs usually normalize after the dose is reduced.
If half of the tests given in a year are abnormal, a liver biopsy should be performed. Speaking practically, however, almost no patients need liver biopsies today if their blood tests are monitored regularly and if appropriate dose adjustments are made to avoid liver complications due to methotrexate treatment.
Dietary supplementation with folate [either 1 milligram (mg) folic acid per day or 2.5 mg folinic acid per week] may reduce the occurrence of LFT abnormalities. Folate supplementation may help prevent liver problems and the severity of side effects in patients taking methotrexate, but it does not substitute for ongoing monitoring and appropriate dose adjustments.
John H. Stone, MD, Rheumatologist
Q: I have tried two different NSAIDs for my OA. One caused my blood pressure to go up and the other caused heart palpitations. Is there one that might help me and be safer?
A: OA is a local condition that causes pain but not necessarily inflammation, so an anti-inflammatory drug may not be necessary. The safest drug you could use is the pain reliever acetaminophen (Tylenol). Acetaminophen can be used as needed in doses up to 4,000 mg per day, and it should not affect your blood pressure or heart.
If acetaminophen does not help, you may need to carefully try another NSAID at a lower dose. Although all NSAIDs are similar, people respond differently to different NSAIDs, and some NSAIDs are associated with a lower incidence of certain side effects. Two you might want to try are sulindac (Clinoril) and salsalate (Disalcid), which may cause less fluid retention and therefore less of an increase in blood pressure.
Don Miller, PharmD, Pharmacist
Q: I have taken methotrexate for six years for RA and took hormone replacement therapy until about a year ago. Recently, I have noticed a lot of hair loss. Might the methotrexate be causing this?
A: You are right to consider that hair loss could be a drug side effect, but there are other factors to consider, too. Because methotrexate is toxic to rapidly growing tissues, such as hair follicles, it can cause hair loss. This is unusual at doses used to treat arthritis but is known to occur at the high doses used to treat cancer. One way to minimize its effect on hair growth is to take a folic acid supplement daily.
Because you say you have taken methotrexate for six years, and just now are experiencing hair loss, I seriously doubt methotrexate is the culprit. It is possible that stopping hormone therapy could be a factor in your hair loss. Changes in hormone levels, such as those that occur after childbirth or around menopause, have been known to cause hair thinning. Many medical problems also trigger hair loss, such as thyroid disease – which, by the way, is more common in people with rheumatoid arthritis (RA).
As upsetting as hair loss can be, you are not alone. An estimated 40 percent of women lose hair by age 60. I encourage you to speak with your rheumatologist about this. He or she should be able to help you determine if some underlying medical problem is causing your hair loss.
If hair loss is serious and no treatable medical problem can be found, you may benefit from one of two prescription medications: finasteride (Propecia) or minoxidil (Rogaine), both of which are approved by the Food and Drug Administration (FDA) to promote hair growth in men and women.
If adding another medication to your regimen doesn’t appeal to you or your doctor, a masking product, such as Toppik or COUVRé, can be applied to the scalp in spray or lotion form to reduce the contrast, and fix the appearance of thicker hair.
Don Miller, PharmD, Pharmacist
Does Methotrexate Stop Working?
Q: I have been using methotrexate for several years. My primary-care doctor said people reach a point at which methotrexate stops working. My rheumatologist says he’s never heard of this. Is it true? If so, why, and what are other options?
A: There is no evidence that people or diseases become “resistant” to methotrexate or other arthritis medications. However, it is common for people with arthritis to change drugs frequently. Sometimes they need to stop a drug due to side effects. For methotrexate, such side effects could include severe nausea, mouth ulcers, liver problems or reduced blood counts. Sometimes patients and doctors become impatient and want to see if something else might work better. Other times it seems like the medication just doesn’t work anymore because it doesn’t control symptoms like it used to; however, the disease may become worse or simply change over time.
Actually, patients tend to stay on methotrexate longer than any other disease-modifying antirheumatic drug (DMARD). This is probably due to its combination of effectiveness, affordability, good tolerability and dosage flexibility. You should feel confident that methotrexate will keep working for you. It is possible that you will need to change or add medications at some point if your disease requires it, but methotrexate is likely to remain effective for you for many more years.
Don Miller, PharmD, Pharmacist
Q: I have been taking four Extra-Strength Tylenol capsules every day for more than three years, but the package says it should not be taken for longer than 10 days. Why? What harm could it do if I continue? Without it, I cannot get out of bed.
A: If you read Tylenol packaging closely, it says not to take for pain for more than 10 days or for a fever for more than three days unless directed by a doctor. Generally, people who need a pain medication for more than 10 days should not be self-medicating; by that time, they should be consulting their doctor to determine the underlying cause of their pain and whether acetaminophen (Tylenol) is the appropriate treatment for it. If you’ve taken acetaminophen for more than three years, I assume you have a diagnosis and your doctor knows which medications you are taking.
Although all medications have side effects, it is generally safe to take 2,000 milligrams (mg) of acetaminophen daily – the amount in the four daily extra-strength capsules you are taking – for long periods of time. Above this dose, if you consume two or more alcoholic drinks per day, you might be at increased risk of serious liver damage. If you do not drink alcohol or use a prescription medication that, like alcohol, affects the liver, it is probably safe to take 3,000 mg or more per day. But, of course, it’s best to speak with your doctor about any medication you are taking.
Dan Clauw, MD, Rheumatologist
When Pain Relievers Cause Stomach Pain
Q: I finally found a medication (piroxicam) that helped my fibromyalgia pain and allowed me to be active again. However, after taking it for a while, I started having heartburn and stomach pain. My doctor had me stop the medicine. The stomach problems are better now, but my fibromyalgia pain is back. Is there any way I can ease the side effects so I can still take piroxicam? If not, can you recommend another similar drug that might help me?
A: Piroxicam (Feldene) is a nonsteroidal anti-inflammatory drug (NSAID), much like ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn). NSAIDs are notorious for causing gastrointestinal side effects, including the heartburn and stomach pain you experience. Many people find those side effects can be reduced or eliminated by taking other types of drugs that protect the stomach and intestine.
The two types of drugs that have proven to be most effective are misoprostol (Cytotec), a synthetic prostaglandin that replaces the normal stomach-protective prostaglandins that NSAIDs wipe out, and the proton-pump inhibitors (PPIs), which include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex). PPIs block the production of stomach acid but may increase fracture risk.
If these protective drugs don’t help, another option is to try celecoxib (Celebrex) – a type of NSAID called a COX-2 inhibitor, which is designed to be safer for the stomach than traditional NSAIDs, such as piroxicam. However, be aware that Celebrex is not appropriate if you have a sensitivity to sulfonamides, a type of sulfa drug. Every drug carries some potential risks, but not treating medical problems can be risky, too. Before beginning any new drug, it is important to review your medical history with your doctor, who can weigh the risks of the medication against the problems you are trying to ease or prevent.
Dan Clauw, MD, Rheumatologist
Q: take prednisone for rheumatoid arthritis (RA). Recently my rheumatologist decreased my dosage from 10 milligrams (mg) to 2.5 mg. I developed a migraine, and it has persisted for more than 30 days. Could decreasing prednisone have caused this?
A: Your question brings up the possibility of prednisone withdrawal symptoms. Prednisone is a corticosteroid hormone related to the cortisone that your body makes naturally. If you take the drug for more than a month, it can slow down your own production of cortisone. A fast drop in prednisone dose then can cause symptoms of cortisone deficiency, such as nausea, fatigue, weakness, muscle pain, poor memory and low blood sugar. Although migraine headaches are not a normal side effect of corticosteroid withdrawal, decreasing your prednisone could have aggravated a pre-existing migraine condition.
Whether cutting back your prednisone is the cause of your prolonged migraine is difficult to answer. A general rule of thumb is to taper prednisone throughout the same length of time that you have been taking it. For example, if you were taking 10 mg per day for three months, you should taper your dose – from 10 mg to 7.5 mg to 2.5 mg – throughout the course of the next three months.
One test of whether prednisone withdrawal caused your migraine is to increase your dose back to 10 mg per day for a few days (with your doctor’s permission, of course). If prednisone caused your migraine, restoring the dose should help you. Thirty days is quite a long time to have a migraine headache. Regardless of whether increasing prednisone helps your situation, an evaluation by your doctor may be in order.
Don Miller, PharmD, Pharmacist
Q: I have been taking the antibiotic minocycline as a disease-modifying drug for the past two months to treat my RA. Is it safe for long-term use? Will it affect my health or my liver?
A: Minocycline, a drug similar to the antibiotic tetracycline, generally is considered to be one of the safer disease-modifying anti-rheumatic drugs (DMARDs). The most common side effects with using minocycline for three months or so are upset stomach, dizziness, discolored fingernails and rashes or dark pigmentation of the skin – especially on sun-exposed areas. It can cause liver damage, but only in very rare cases. Your doctor should be examining you every few months and sending you for lab tests to make sure minocycline is working for your RA and not causing any side effects.
Minocycline is effective in about 60 percent of people with RA who use it. However, it often is not prescribed because it does not have FDA labeling approval for this use, and it is a relatively weak DMARD compared with methotrexate, leflunomide (Arava) or the biologics (Enbrel, Humira, Kineret, Orencia, Remicade and Rituxan). It isn’t the antibiotic properties, but the effects on the immune system and the ability to inhibit enzymes that break down cartilage and connective tissue that make minocycline (and other tetracycline drugs) so effective.
Don Miller, PharmD, Pharmacist
Q: When I took NSAIDs [nonsteroidal anti-inflammatory drugs] on two occasions for my psoriatic arthritis, I experienced so much joint swelling that I had to have my knees drained. My rheumatologist said the reaction occurred because NSAIDs restrict blood flow through my kidneys. Can you explain why it happened? Do you know of medications that may help without having this effect?
A: It is true that NSAIDs, like aspirin, ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn), can restrict blood flow through the kidneys. However, when this happens you would typically have fluid retention throughout the body; swelling might also occur in just the lower extremities, such as the ankles, due to the effects of gravity. Patients may also experience weight gain and increased blood pressure.
I suspect the localized swelling you experienced in your knees was not caused by an effect on your kidneys. Rather, it may have occurred as a result of your immune system reacting to the presence of aspirin and ibuprofen. While some people have a systemic allergic reaction to aspirin and NSAIDs, resulting in hives or difficulty breathing, it is possible for a more localized reaction to occur, which could have been the case for you.
Given your history of intolerance, avoid using any of these drugs in the future. A non-NSAID pain killer like acetaminophen (Tylenol) should be safe. Other agents effective in the treatment of psoriatic arthritis include the disease-modifying antirheumatic drugs (DMARDs) like cyclosporine (Neoral), methotrexate and sulfasalazine (Azulfidine). Systemic or intra-articular steroids may also be of benefit. And three biologic agents that stop the inflammatory reaction from occurring – adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) – are now approved by the FDA for use in people with psoriatic arthritis.
Don Miller, PharmD, Pharmacist
Q: I have rheumatoid arthritis (RA), for which I take both prednisone and methotrexate. Now my doctor wants to prescribe hydroxychloroquine (Plaquenil) for me. Have you ever heard of someone taking three drugs at once? Is this safe?
A: It is common for physicians to prescribe a combination of low doses of prednisone and drugs like methotrexate for patients with rheumatoid arthritis. In selected cases, as in your case, physicians are adding on additional drugs. These combinations of drugs are used for patients with RA whose disease has not responded well to a single drug or to two drugs. A number of clinical studies have shown that patients treated with certain drug combinations do better with no greater incidence of side effects than those taking individual drugs. In these situations, it's important to have your disease managed by a physician experienced in the arthritic diseases.
Q: Several years ago, my previous physician prescribed a medication called Butazolidin -- the only medication that has helped me manage the pain of RA. That physician retired and my new one says Butazolidin is used only for horses. Is this true? Isn't there some way I can get this medication?
A: Butazolidin is the brand name of a NSAID called phenylbutazone. Currently, no
I'm sorry that other drugs have not helped you the way phenylbutazone did, but with the high numbers of NSAIDs on the market -- and all the new drugs coming out shortly --I hope you and your doctor will find one that brings you relief.
Donald R. Miller, PharmD, Pharmacist
Q. I have been prescribed varying dosages, sometimes up to 20 milligrams of methotrexate per week, for the past two years. What should I be aware of concerning methotrexate use?
A: Methotrexate is an effective and usually well-tolerated medicine for RA. But, like any drug prescribed for any reason, it does have potential side effects.
To get the most benefits from the drug and reduce the likelihood of complications, it's important to heed the following advice:
* Take methotrexate exactly as directed by your physician.
* Ask your doctor if you are unclear about the medicine's dosing or possible side effects.
* Don't take other drugs - including over-the-counter ones – without first speaking to your doctor. Certain pain-relievers can act to increase the effects of methotrexate.
* If you notice any unusual bleeding or signs of infection, tell your doctor. Methotrexate can lower the number of blood platelets (which help the blood to clot) and white blood cells (which normally fight infection).
* Don't get any vaccinations without informing the health-care provider that you take methotrexate. Certain vaccinations can be dangerous in people whose immune systems are altered by drugs such as methotrexate.
* Don't drink alcohol while you are taking methotrexate. That's because one of the most serious long-term side effects of methotrexate is liver damage.
* You will decrease the chance of liver problems when you avoid alcohol.
* Call your doctor immediately if you have trouble breathing. In rare cases, methotrexate can cause inflammation of the lungs. Although there is no known way to prevent this side effect, prompt treatment is essential if it occurs.
Don Miller, PharmD, Pharmacist
Q. I have heard that malignancies can occur in people taking the drug Arava. Because I have a history of Hodgkin's disease (a cancer of the lymph nodes), as well as RA, do you think I should avoid this drug?
A. Leflunomide (Arava) is a relatively new drug for the treatment of rheumatoid arthritis (RA). The drug reduces joint pain and swelling and, in addition, can slow damage to cartilage and bone, as shown by X-ray. There are no studies showing leflunomide increases cancer risk; however, published studies on leflunomide have involved limited numbers of patients and, because the drug is relatively new, it is really too early to know whether the drug puts people at serious risk of malignancy somewhere down the line.
This potential to cause malignancies has been raised for a number of other RA drugs. Further epidemiological studies are needed to determine if, in fact, drugs do significantly increase cancer risk. Complicating this issue is the fact that RA itself may be associated with an increased occurrence of certain malignancies. In that case treating RA aggressively with medications may actually decrease cancer risk.
I have no easy answer to your question. The best path is to consult both a rheumatologist (arthritis specialist) and oncologist (cancer specialist) and decide which arthritis drugs will likely work best and have the fewest side effects and risks.
Interestingly, some drugs used to treat malignancy, such as methotrexate, are also effective in treating RA.
David S. Pisetsky, MD, PhD, Rheumatologist
