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Revisiting methotrexate for psoriasis
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When it comes to treating psoriasis, sometimes the old becomes new. For the better part of five years I have treated my psoriasis with the newest, latest, and most technologically advanced biological drugs available. My basic treatment menu has included Amevive, Enbrel, and Humira. Each one's effectiveness varies and lasts for a limited time. Now that I am at yet another decision point I am rethinking using methotrexate (MTX).
According to the National Psoriasis Foundation, MTX was first used to treat cancer in the 1950's but they also found it could be used to treat psoriasis. It works to slow down the hyper proliferation of skin cells characteristic of psoriasis. Despite all the fancy new drugs out there, dermatologists still use MTX to control severe cases of psoriasis. My dermatologist asked me to consider using it again a couple weeks ago.
The main concern with MTX use is liver scarring. I'm not sure exactly what current practice is but in the past had two liver biopsies to check my liver. I started taking MTX in my early 20's while in college. MTX represented my first foray into systemic medications to control my psoriasis. My dermatologist in Sacramento (I went to school at UC Davis) wanted me to first get a baseline liver biopsy (depicted below). She explained to me that the biopsy is an outpatient minor surgical procedure where they grab a piece of my liver by placing a needle between my ribs. Okay, that's not the most technical way to say it but what I can say is that it hurt a lot more than I thought it would! Thankfully my liver was fine. The dermatologist told me that we would need to revisit the liver biopsy every 1.5-2 grams of MTX use.
I started with a few 2.5mg pills per week. My maximum dose was seven pills, or 17.5mg/week. I usually took it in split doses over a 24 hour period to minimize side effects such as nausea or fatigue. When those side effects increased I also took folic acid to mitigate those unwanted effects. I remember sharing about taking MTX with a colleague. She used a Chinese term to describe what she thought of the medicine: "du yao" or poison medicine. After a while the thought of taking it and the smell of the "poison medicine" made me want to gag but I continued on.
Back then it was a miracle drug for me as I cleared completely for some months. But once it lost effectiveness I broke out horribly. I stopped just before needing to take my third liver biopsy. Since I had good response the first time I went back to it about five years ago. Unfortunately, my body couldn't tolerate it. I endured nausea and fatigue for up to 72 hours or more after taking MTX. I tried taking MTX as an injection in my hip, prescription antacids to counter the acid in my stomach, and resting for long stretches. The second time around MTX neither cleared my skin nor allowed me to function much at all the days after taking it.
I never did have that third liver biopsy as I stopped just before crossing the 2 gram threshold. I was told that even if I had some minor damage the liver could recover from it after stopping. I don't drink alcohol but I was told to absolutely avoid alcoholic drinks while on MTX. Monthly blood tests also checked for liver function, blood counts, and any other potential abnormalities.
Of course, if you're thinking about taking MTX do some research for yourself and really talk it over with your doctors. I'm not sure if it's right for me this time around, especially given the way I reacted a few years ago. But I feel with psoriasis treatments I can't afford to completely eliminate potential options. I'm thinking of trying a smaller dose with Enbrel so I can stop taking Neoral for a while.
Video: ESDV 2018 Annual Conference, Dr. Mohamed Banhawy Lecturing (Aspirin in Dermatology)
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