Poverty is the second related issue. This puts biologicals out of reach for most. Therefore, in India we mostly use DMARD combos with bridging therapy, by way of depot-GC injections or orally for a short term. However, this creates problems. Because GCs are the cheapest and the most powerful pain reliever, the patient quickly perceives this as the real drug. With inherent difficulties in travel to reach a rheumatologist (e.g., poor facilities for differently abled persons in India) and the involved expense, they fall back on the magic pill! These are kept for handy use and popped frequently without recourse to further medical advice. Over time, as the GC dose becomes less effective, they often simply increase the dose on their own. It’s important to note that in India, most drugs, especially GCs, can be obtained over the counter without prescription. The appearance of such patients when they finally decide to return to the rheumatologist after a gap of five years or so for further treatment is familiar to rheumatologists, especially of my generation: what we used to call a steroid wreck—an obese, wheelchair-bound, semi-blind person with advanced Cushingoid features, extensive steroid purpura, some healed and some not-so-well-healed fractures, diabetes and hypertension, along with advanced joint damage and deformities.
After dealing with such patients for 47 years, I have two important take-home lessons. First, pharmaceutical companies should change the taste: Prednisolone tablets are easy on the palate. If a GC pill were extremely bitter, it might discourage casual popping, as people do with gum or candy, whenever there is pain. Methylprednisolone (MP) is such a tablet. In addition to being more expensive, it tastes horrible, so bitter that patients plead with me not to prescribe it. So I started substituting MP for prednisolone.
Second, low-dose-methotrexate (LD-MTX) intolerance was becoming a major problem above the 15 mg/week dose. From oncology colleagues, we learned that a moderate dose of GC prior to chemotherapy prevents nausea and other unpleasant sensations of chemotherapy. We started giving MP, varying from 4 to 16 mg weekly about 30 minutes before the LD-MTX dose. Whether it prevented or reduced LD-MTX intolerance was not studied systematically, but unexpectedly it was noted, on withdrawing the weekly MP dose, that several patients soon returned, complaining of increased pain and/or swelling in the joints. We then systematically analyzed patients who had been taken off the weekly MP dose. On reinitiating the weekly dose of MP, symptoms subsided quickly.
