Dr. Matteson would start by treating the infection and prescribing steroids. Depending on the degree of disease, he would continue with low-dose prednisone or possibly use triple therapy, but probably would not rush to resume infliximab. Dr. Kremer agreed about not going back to the biologic too quickly and added that he would treat the patient with standard disease-modifying antirheumatic drugs (DMARDs). Dr. Ritchlin concurred, adding that he might hold off on the prednisone.
Some panelists recommended continued antibiotic use and switching to abatacept as the biologic of choice. This recommendation was based on lower rates of Mycobacterium infections in the clinical trials and positive animal data. Another biologic that was discussed was rituxan as an alternative in this setting.
Another potential complication in RA patients, nonhealing ulcers, highlights the potential of working at cross-purposes with other specialties. The rheumatologist may be asked to discontinue a patient’s DMARD therapy to facilitate healing of pretibial ulcers, for example. Many ulcers that are seen in RA are immune and will do better when steroids are discontinued, Dr. Kremer said, but he would not hold methotrexate because that could result in worsening of the disease—which he has seen in practice.
“For management, I endorse what [Dr. Kremer] said and recommend that you evaluate these patients very carefully for underlying physiology of the ulcer,” Dr. Matteson said, which likely means performing a biopsy.
Options for Methotrexate
Although methotrexate is a popular therapy in rheumatic disease, it is not always effective. Options for addressing this are to switch to subcutaneous therapy or to another drug.
A “failed study” from 2011 that looked at methotrexate in patients with psoriatic arthritis (PsA) showed no increased efficacy of the drug versus placebo with 15 mg per week, Dr. Ritchlin said. Although this study used a low dose of the drug and had a high dropout rate, “none of us are thrilled with the results in our offices with psoriatic arthritis patients,” he said. “There is a subset of patients who may respond to methotrexate, so we do use it, although we don’t have evidence to support this approach.” He suggested monitoring for four to six months and then adding an anti-TNF or switching all together if there is no response.
To ensure the patient absorbs therapeutic doses of methotrexate, switch to subcutaneous administration, Dr. Kremer said. The bioavailability of oral methotrexate declines by as much as 17% when the dosage reaches 15 mg per week, compared to 100% bioavailability at 7.5 mg.
