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What is A Rheumatoid Ahritis patient on Methotrexate, Steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management and explain in detail?
Methotrexate:- * Methotrexate, a first line Disease Modifying Rheumatoid Ahritis Drug is the first choice of drug in management of early Rheumatoid Ahritis. * It is the first choice conventional DMARD and an anchor drug chosen for most Anti-Rheumatoid ahritis combination therapies. * Methotrexate is used in dosage of 10-25mg/week oral or subcutaneous along with Folic acid 1mg/day as a pa of toxicity amelioration. Subcutaneous dosing is better in terms of bioavailability and pharmacodynamics attained. Recommendation Summary for use of Methotrexate in RA: - * Administration of a high initial dose of Methotrexate followed by rapid down titration to optimal dose can improve the response to oral Methotrexate without much compromise on patient safety or tolerability. * Response to treatment following optimal oral Methotrexate takes a minimum of 3 months, and at least 6 months to monitor accurate effect on disease progression * Patients not responding or showing inadequate clinical response to oral Methotrexate may be "rescued" by switching to subcutaneous Methotrexate. * While changing over from oral to subcutaneous dosing of Methotrexate, the same oral dose received by patient should be matched and given, following which on a later course, the dose may be altered. * If Methotrexate monotherapy fails to produce clinical improvement, another agent may be considered for combination. Ref:- Goodman & Gilman's Pharmacological basis of Therapeutics 13th Ed; Pg Num:- 2537