Welp these creams don't work... Let's switch to a chemo drug! All about Methotrexate.

This will be the first of my focus on medications series.  I picked Methotrexate because it is usually the first in line for the heavy hitters of meds when you have unresponsive/ moderate to severe Psoriasis and or Psoriatic Arthritis.  

For those not in the know yet Methotrexate is often referred to as MTX.  It is considered a Disease Modifying Antirheumatic Drug (DMARD).  It is also used in higher doses to treat cancer.  Many times starting you on MTX is a means to an end as most insurance companies require you to fail on at least one (and sometimes specifically MTX) before you can start on a biological therapy.

So on to the nuts and bolts.  MTX is available in pill and shot form.  It is usually taken 1 time per week for Psoriasis and Psoriatic Arthritis.  It was approved for use for Psoriasis patients in the 1970's.

What MTX does:  MTX slows the development of psoriasis by suppressing the part of the immune system that is causing the increased development of skin cells.  It does this by binding to and inhibiting the enzyme responsible for excess skin production.  Recent studies are finding that MTX does NOT have significant effect on Psoriatic Arthritis as it does on Rheumatoid Arthritis,  however it is still a prerequisite for many other meds which do help Psoriatic Arthritis, and it does show improvement in Psoriasis.  It does act as an immuno suppressant so may slow the progression of Psoriatic Arthritis even if it is not giving relief as many other DMARDs and Biological medications do.

Potential Side effects: Commonly known side effects of MTX are nausea, headaches, hair loss, mouth ulcers, and fatigue.  It is also known to be very stressful on the liver and long term use is known to cause liver toxicity.
The copy and paste version of side effects are...

• dry cough, shortness of breath;
• diarrhea, vomiting, white patches or sores inside your mouth or on your lips;
• blood in your urine or stools;
• swelling, rapid weight gain, little or no urinating;
• seizure (convulsions);
• fever, chills, body aches, flu symptoms;
• pale skin, easy bruising, unusual bleeding, weakness, feeling light-headed or short of breath;
• nausea, upper stomach pain, itching, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); or
• severe skin reaction -- fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.

Common side effects may include:

• vomiting, upset stomach;
• headache, dizziness, tired feeling; or
• blurred vision.

You will need to have liver function tests done regularly (usually quarterly) to make sure that MTX is not over taxing your liver.

Ways to minimize side effects:  Because many people do experience varied level of side effects while taking MTX it is a common point of interest on community boards about Psoriasis and Psoriatic Arthritis.  Many people find that just switching from the pill form to the shot form of MTX brings a lot of relief.  The time that you take your MTX can make a difference too.  Taking your medication before bed so that you sleep through the worst of the stomach upset can help.  Most physicians will prescribe folic acid with MTX to help combat side effects.  Folic Acid is generally taken daily EXCEPT for the day you take your MTX.  Other things that help with nausea are ginger products (ginger snaps, ginger tea, sugared ginger), hotpad on the stomach area, anti nausea medications, the BRAT diet (Bananas, Rice, Applesauce, Toast)

My personal experiences with MTX:
I have been on MTX 3 times over the last 10 years.  The first time was solely for Psoriasis.  I was on the pills and did experience some nausea, but taking them at night was enough help for me to not be in too much discomfort.  I took solely MTX for about 6 months and it worked well on my Psoriasis.  During this time I was diagnosed with Psoriatic Arthritis and it was decided to put me on Enbrel and drop the MTX.  The second time I was on it I was on Remicade and it was added to try to increase the effectiveness of the Remicade and prolong the amount of time that I could stay on Remicade as I was at max dose max/frequency of Remicade.  This time I started with the pills and experienced severe nausea and headaches.  I was switched to the shot form and again taking it at night and the nausea reduced and I no longer had migraine level headaches.  After about a year the combo of Remicade and MTX was causing my liver function tests to come back high so it was decided to stop the MTX.  The final time was after I quit Remicade.  My Psoriatic Arthritis was no longer responding to Remicade so it was decided to try MTX alone for a while since I had responded well to it before.  This time I started with the shot form.  I had severe nausea, vomiting, hair loss in large clumps, severe headaches, and very high liver enzyme tests.  I was only able to tolerate it for about 2 weeks before the doctor took me off of it.

So there you have the good bad and ugly of Methotrexate.  I know it can be a scary option, but many people do respond very well to it on it's own for many years.  None of the advanced meds are an easy choice to choose so if you are at the point in your disease that DMARDs and Biological options are being discussed this is an option.

Please remember I am not a medical professional.  Discuss all your treatment options with your specialist and do your own research.  Be your own best advocate!  Be proactive and be educated.

Web Resources:
1. http://www.psoriasis.org/about-psoriasis/treatments/systemics/methotrexate

2. http://www.medpagetoday.com/Rheumatology/Arthritis/33895

3. http://www.drugs.com/sfx/methotrexate-side-effects.html

4. http://www.webmd.com/digestive-disorders/brat-diet