Springboard message from Dr. Bachman

Recently there was a discussion regarding the role of family physicians in using methotrexate in rheumatoid arthritis. The conversation was whether family doctors should start methotrexate treatment without referral vs. referring patients to a rheumatologist because of legal consideration. Whenever disagreement over a topic is brought up it can become a learning issue.

Methotrexate for family physicians is 10 years old, but remains an excellent review with summaries of initiation and follow-up  http://www.aafp.org/afp/20001001/1607.html

Methotrexate concentrates in the kidneys, gallbladder, and spleen, as well as in the liver. Renal excretion eliminates 60 to 95 percent of a dose. Tubular secretion, reabsorption and glomerular filtration are all involved in the renal elimination of methotrexate. Therefore, methotrexate is contraindicated in any patient with a creatinine clearance of less than 50 mL per minute.

The UK uses shared care agreements with doctors who initiate the treatment being legally liable http://www.lmsg.nhs.uk/SharedCare/pdfdocs/MethotrexateSCAv2_1_200806.pdf

American Family Physician editorial talks of early referral to rheumatologist
http://www.ncbi.nlm.nih.gov/pubmed/16190501?dopt=Abstract

American College of Rheumatology 2008 recommendations states physician although in references talks about referring to a rheumatogist in other literature in the first three months of RA

http://www3.interscience.wiley.com/cgi-bin/fulltext/119635887/HTMLSTART?CRETRY=1&SRETRY=0

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689523/?tool=pubmed Shows recomendatons for methotrexate and variation among rheumatologist

Law suits were certainly an issue. The ones I found were when doctors just gave the wrong treatments.  ie. In the treatment of rheumatoid arthritis and psoriasis there are given MTX doses ... she had been prescribed by her family doctor 20 mg/day MTX for 8 days. This caused the patient to die

So be careful and make sure when you see methotrexate on the list that you note this is one dangerous medication.

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