Kickas.org Forums Treatments, Drugs and Alternatives Anti TNF and other biological medications Enbrel and MTX

Well, the time has come, Arava isn't keeping the monster under control any more but at least we had a good run, over 3 years and not until the last few months that the inflammation has made a come back. So the next step is Enbrel. Question. My rheumy wants to combine Enbrel with a very low doese of MTX, she claims it will boost the effects of the Enbrel and also lessen the possibility that Enbrel will become ineffective over time. I hate MTX! But when I was on it I was of course on a larger dose, and always felt sick. Is anyone out there on both Enbrel and MTX? If so, what is the dosage for the MTX?

Thanks.

Cheryl

Hi Cheryl

After taking 15 mg of MTX once a week for 8 weeks and getting no improvement, my Rheumy has now added Enbrel to my treatment. She said when I get good result, we'll discuss about whether continue or not the MTX. In the meantime, she believes the combination works faster.

After one Enbrel injection, my morning stiffness and pain has already lessened !

Olivia

Cheryl,

I have never taken MTX, so I dunno...BUT, I can tell from my experience with Enbrel...I needed the Celebrex. I am off Celebrex now and taking Mobic. Will begin AGAIN on the Enbrel March 7th, with this combo. I will let you know how it goes!!

Good luck, Sweetie!!
Holly

I have taken MTX by itself and couldn't stay on it long enough to see if it would work. Rheumy stresses that this is a very light dose, maybe I'll try it and see if I can tolerate it plus the Enbrel. Hate to think of biting the bullet and going on Enbrel and having it work for a time and then not work. Down here in the Florida Keys we live on the water, which means year round snorkeling and diving. With the progressive stiffness and the probable damage to my body, without some intervention it's only a matter of time before getting on and off the boat will be impossible, which means I'll a a landlubber and that's not why we live down here! Risk versus benefit, I guess.

I can imagine when the Salk vaccine came out there were many people more willing to risk a crippling illness than to prevent it due to the fact that it was new and no one knew long-term what the effects would be. Well, we're sort of in the same boat. And what about smallpox? When smallpox was still a world wide problem everyone got vaccinated - - and there were some deaths. But risking smallpox made the vaccination worth the risk. If smallpox once again (through terrorist activity or whatever) became a real risk, I imagine we'd all be lining up again.

Thanks for the reply

Cheryl

Hi Cheryl,

I can't help to answer your question on combining these meds, but I've also been debating a similar decision. I've been asked to consider starting MTX also, to go along with the Remicade treatments I started back in Nov. My initial instinct is not to rock this very nice boat since everything is working so well right now, but I'm trying to do some research before making up my mind.

In reading on PubMed, I just found this study, which is the first time I've read of any sustained benefits from a biologic... even after it's withdrawn! The study was with RA patients, (naturally), so I thought you may have an additional interest.

Take care,

Thanks! It would be wonderful if I only had to be on this powerful and potentially dangerous drug for only a year or two and then stay in remission. I printed this out to take to my rheumy next Friday.

Cheryl

Hi Nina,... I was kind of hoping you'd notice this and pop in with some advice or helpful info! If not, I was planning to send you a PM with a few questions.

I think my biggest concern is the possible nausea, which is something I'm prone to easily and something that would certainly diminish the quality of my days. This is the first time I've felt well in 24 yrs, and I just hate the idea of going backwards. However, if it will help to maintain this new found quality of life then that is the most significant consideration.

I have read that MTX should help extend the benefits of Remicade. What I have not been able to find out is whether Sulfasalazine might do the same. I am already taking SSZ. Also, I was surprised to read (lost the reference) that MTX could elevate the risk potential for liver toxicity especially when combined with nsaids. I'm also presently taking Voltaren.

My concern is that I will be asked to start MTX and drop SSZ and/or Voltaren, both of which cause me little, if any, noticeable side effects. I'm also worried that if I'm unable to tolerate MTX, then SSZ may not work as well for me the 2nd time around.

I have an appt for a discussion this week with my regular Rheumy (not the same one who's asked me to consider mtx) so I'd like to go in armed with the appropriate questions. One of which may be to ask why the protocol here differs so much from the one used in Sweden.

I was given three reasons to consider the addition of MTX (by the guest-starring Rheumy). He felt adding MTX would help to lower the cost burden by enabling me to lower the dose and therefore the risk exposure (I'm only on 3 mg/kg), spread out the dose while maintaining effectiveness (just had my 4th infusion after a 9 wk interval), and to help prevent the possibility of developing antibodies.

I was left with the distinct impression that 'cost burden' was his prime motivation, although I absolutely understand the need to use our limited public healthcare monies responsibly. I just can't help but wonder... if I stay on SSZ and manage to avoid treatment breaks would this be sufficient, and I don't know if there've been sufficient studies yet to really know any of these answers.

I am also curious, if the MTX is to prevent the development of antibodies to the mouse, then why is it being suggested that Cheryl take it in combo with Enbrel? I feel like I am missing the basic reason which explains why the docs like MTX so much.

I really appreciate all your helpful input to these discussions, Nina!
Thanks a bunch!
mig

Hi Mig,
This reply turned into a small novel. Keep in mind that much of the stuff is parroting from what I've been told by drs or have read.

I was on both MTX/SSZ/prednisolone for a couple of months, and my liver tolerated it well. I was on MTX + NSAID’s over a shorter period of time only, so I can’t say much about that. It’s true that MTX toxicity (and NSAID toxicity) can increase with concomitant use, although many people have no problems with the combo.

Also, you might be able to get by without NSAIDs on the Remicade/MTX combo. I don’t take NSAID’s on a frequent basis (except for migraines or the occasional AS-related joint pain) since the Humira/MTX usually controls things well enough on its own. I actually feel much more uncomfortable with NSAID’s than I do with MTX.

I have never had any nausea from MTX even on the maximum dose of 25 mg/10 pills. If you do get nausea, you can switch to injections, which according to my rheumy often is very helpful against nausea. If you start out on a tiny dose like 1 pill and then go up gradually, it will probably be easier to tolerate too. Since you tolerate both SSZ and Voltaren, you must have an iron-clad gut, though!

I checked the article about the Remicade study I was in (unfortunately in Swedish only). You had to fail either SSZ 3 g/daily and/or MTX >= 15 mg. Those not on MTX were put on it, but only one of those on SSZ only remained on SSZ along with MTX. The study also suggested that an infusion interval of 8 weeks was necessary to maintain results (although keep in mind that we were only 9 patients, so it was a small study). The Remicade dosage was around 3 mg/kg, just like yours.

Mattias (Kotte) is also on MTX/Remicade, and I think he’s on just a small dose MTX nowadays. He might have some additional insight on MTX and Remicade in AS.

From what I’ve seen, Enbrel+MTX works better in RA than just Enbrel or just MTX, although it seems unclear if it’s because MTX boosts the effects of Enbrel or if it’s just because both drugs are effective in RA, but work in different ways. MTX doesn’t seem as effective in AS – at least not for the spine – as it is in RA and psoriatic arthritis. MTX along with Enbrel isn’t necessary in AS here in Sweden, although many AS’ers that get to try Enbrel here are, or have been, on MTX.

We too have public healthcare, so I think part of the reason MTX is used along with biologicals is to lower the costs. The main reason for using it along with Remicade, though, seems to be to lower the risk of infusion reactions.

Some parroting from the Humira prescription info: MTX boosts plasma levels of Humira, (which is probably why it’s used). The info also mentions that patients not on MTX along with Humira who have insufficient results, can benefit from Humira 1x/weekly (instead of every 2 weeks). Oddly enough, antibodies against Humira is mentioned; that 12% of those not on MTX along with Humira developed antibodies, vs 0,6% of those on MTX +Humira. It wasn’t mentioned whether those antibodies cancel the effects of Humira and/or cause allergic reactions, but from what I’ve been told, allergic reactions from Humira is very rare. I wonder if those antibodies can lessen the effects of Humira. Have to ask my rheumy why this happens despite that Humira is human and what those antibodies potentially can do. It does seem less common than in Remicade, though. Since Humira isn’t approved for AS yet, there isn’t anything about usage in AS.

Either way, I hope you’ll be able to stay on Remicade, since you’re having such good results from it.

...and here I am. Hi Nina and Mig

As Nina wrote, I'm on a low dosage (5 mg a week) MTX together with my Remicade. My rheummy lowered the MTX due to elevated liver enzyme levels. I actually suspect the culprit was the combination MTX+Remicade that caused the elevated levels. Look at my ALT (ALAT - amino alanine transferase) history below. I was on 12.5 mg MTX a week at the beginning of my Remicade treatment. When I was on only MTX (and NSAID), I was quickly going downhill. It didn't help at all. At least I found out that the Sulfasalazine I've been on earlier actually worked to some degree, at least compared to MTX. To my understanding (=Internet) MTX is used to both increase the effect of Remicade and lowers the risk of allergic reaktions to the Remicade. In the case of Enbrel and MTX, there seems to be a similar increase of the effectiveness of the treatment when taken together.

The switch from Sulfasalazine to MTX and then to Remicade marked with vertical lines, and the reference level of 0.8 marked with a horizontal line.

Now my ALT is more or less normal (haven't got any new data since last year).

/Mattias