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

Hi Nina and Mattias,

Wow! Thanks so much for all this great info and helpful input! I will have quite a bit to discuss at my Rheumy appt., and probably way more than time will allow.

I can imagine being able to avoid nausea only if I drop the nsaid and/or ssz before trialing mtx. Right now (and even before starting Remicade), if I took anything over a T3 I'd be instantly struck with nausea to the point of complete intolerance. But, if I do drop voltaren and ssz to start taking mtx, then that means rocking the boat in no small way. Yep, I am very lucky to have an iron clad stomach and good tolerance for what I'm taking currently.

I still can't find info regarding trials that relate to ssz and Remicade alone, to know if the effectiveness of Remicade could be maintained this way, or if they just haven't studied this combo yet. I keep wondering if ssz has any potential (or none) to hinder development of antibodies against remicade. In my case, boosting the effectiveness is not a driving issue to make a switch, yet.

Mattias, thanks for including the great visual history of your levels as you progressed through meds. It certainly looks like mtx and remicade are both culprits in your case for elevating liver enzymes. I'm glad to see your levels are returning to normal on the lower dose. I also found a disturbing contrast in noting the frequency of your lab work. No-one here seems to care or ever ask for blood except when I push them to do it. I will not be adding mtx without assurance they'll keep a closer eye on things.

I have no real need to make a change right now on the basis of how well I'm doing, but I'll see what my fav Rheumy has to say about the potential for antibodies crashing the party. Prevention may be the most important long term consideration, but preventing liver troubles or antibodies to remicade is where a crystal ball would really come in handy.

I really appreciate the time you've both taken to help answer some of these questions for me, and hopefully it's helped Cheryl too! (Sorry to have side-tracked your original query Cheryl, I really didn't mean to hyjack your thread!) It is good to know that mtx boosts the effectiveness of Enbrel also, although the reason for it's inclusion may differ somewhat between the biologics. All this is helpful towards making the best treatment decisions and limiting our risk.

Thanks again!

Mig,

Haven't seen anything either about SSZ/Remicade and antibodies. I was going to mention it after writing that those on SSZ in my study had to go on MTX in order to get Remicade, but then I forgot to. We have extensive registration of biologicals and their effects/side effects here, and the clinic I go to is one of the hospitals involved in collecting data from the whole country. If I remember it at the next visit, I could ask my rheumy.

It's a bit odd that you don't go for bloodwork often. I still go monthly (although part of the reason is that my disease activity was very high in the past and they wanted to keep an eye on it), and the first 6 weeks after starting Humira, I went every 2 weeks (although part of it was for research.When starting MTX or other regular DMARDs, you usually go every 2 weeks for the first 3-6 months, then monthly and possibly bimonthly. I have had at least monthly bloodwork during the almost 5 years I've been on DMARDS (SSZ, MTX, and the three anti-TNF's). On in-between visit bloodwork, they check my liver, kidneys, hemoglobin, white blood cells, platelets and CRP, and at rheumy visits they do that + ESR (sed rate) and 8 other vials I'm not sure what they do with. Some of it goes in their freezer for future research purposes.

Keep posted on what the rheumy says about Remicade/MTX,

Nina

Hi all,

I did get in to see my Rheumy, but then kept getting side-tracked and nearly forgot to follow up on this topic.

When I told my regular Rheumy about how the infusion clinic Rheumy wanted me to consider starting on MTX in combo with Remicade, he disagreed with their plan for a number of reasons.

The first thing he explained to me was that the existence of these anti-bodies has yet to be proven as fact. No-one has actually seen them! So that potential is still speculative.

The next thing he said was that MTX has only proven to boost the effects of Biologics in RA, and that the same cannot be said for AS.

He was also happy to hear that I'd challenged the other Rheumy on Sulfasalazine. It was his opinion that SSZ may well prove in future to be equally effective against the development of antibodies (in the event antibodies to mouse protein really do exist). Plus, the toxicity of MTX is more concerning than that of SSZ, so he feels this is not a wise direction to take, in my case. The increased risk of developing chest infections is greater for patients on MTX compared to those on SSZ, which is of concern for many AS patients (more so than RA patients) due to limited chest expansion. He also suggested that there is no proof that the addition of MTX might help to extend infusion intervals.

A close friend of mine kindly sent me this interesting (albeit small) study done in 2005, and found on PubMed, and the conclusions seemed particularly relevant to our discussion.
CONCLUSIONS: Infliximab in combination with methotrexate was a safe and efficacious therapy in AS over a six- month period and was associated with significant regression of MRI determined enthesitis/osteitis. However disease flares were reported 8 weeks after last infusion indicating that the addition of methotrexate failed to extend the infliximab dosing interval.

Also from PubMed, in a related articles search, I found this:
REVIEWERS' CONCLUSIONS: There was no statistically significant benefit of MTX in the examined outcomes for AS patients. High quality, larger sample and longer period of randomized controlled trials (possibly with higher dosage of MTX) are needed to verify the uncertainty about the efficacy and toxicity of MTX for the treatment of AS.

I could tell by my Rheumy's expression that he was quite annoyed to learn that the infusion clinic downtown had not been doing regular bloodwork checks on me. He wants my lab work monitored every 8 weeks. He sent me himself to the lab, and assured me he'd communicate further with the clinic on this, and will also recommend that my course of treatment be unchanged to include MTX. This was my initial hope and I was relieved to find he was in complete agreement with me, rather than his collegues. He felt the difference of opinion was due to the fact that the 'other' Rheumy is mostly involved with RA and Crohns patients (where this treatment direction would make more sense). Perhaps I should consider sticking a big AS label on myself for future infusion appts.

Thanks for listening!

Hi guys, new to the Kickas boards

I was on MTX for about 9 months (10mg then 20mg) with little or no impact on my AS, I then decided to give it a break for 3 months. Following that, I started a course of Enbrel and went back on the MTX (10mg), I haven't come across any conclusive evidence to say that Enbrel\MTX have some sort of symbiotic relationaship, I would rather not have to take the MTX if had the choice.

On a more positive note, I have had gotten grat relief from Enbrel over the past 4 months or so, long may it continue

CJ

Just wanted to add to the discussion
I was on MTX and Enbrel for over a year when I developed mouth sores and had to be taken off the MTX (this is a side effect of MTX). Previously I was on MTX for several years with no mouth sores-so who knows? But I can definitely say I am worse in terms of flares, pain, more frequent problems, etc. since going off the MTX. I do have Crohns/Inflammatory Bowel and Psoriatic Arthritis, so this combination is indicated for these conditions, according to my rheumy. Sometimes I am tempted to start up a short course of pred just to get over a bad time, but I really hate the effects it has on me. This is a problem we all face when they start mixing meds trying to tailor it for our particular diseases. Hope you are feeling ok and that this discussion is helpful.

Hi Mig,

The abstract you posted is consistent with what was observed in the study I participated in. The role of MTX together with Remicade was not investigated in this study, though, only the effects on Remicade in AS (it was an early study). All participants were on MTX along with Remicade, and seemed to need a maintenance dose of Remicade every 8 weeks in order to control disease activity. This too was a very small study.

Yes, MTX doesn’t seem to be very effective in AS – at least not in the spine. This seems to be the general consensus over here too. Like I mentioned before somewhere in this thread, AS’ers over here don’t have to take MTX along with Enbrel or Humira.

I did not have good results from MTX alone either, but I’m staying on MTX, because it has shown to elevate plasma levels of Humira, because of the peripheral arthritis + other autoimmune problems. While being temporarily off MTX last year, I noticed a quicker fade in Humira.

The part about the existence of the antibodies against Remicade has yet to be proven as fact makes me wonder a bit, though. According to our national version of the Physician’s Desk Reference (bear with my translation) :

“In clinical studies, where single and multiple doses of 1-20 mg/kg infliximab were used, were antibodies against infliximab detected in 14% of the patients receiving immunosuppressive therapy and in 24% of the patients without immunosuppressive therapy. “

“Patients that developed antibodies against infliximab were more prone (appr. 2-3-fold) to developing infusion-related reactions. Concomitant use of immunosuppressants reduced the frequency of infusion-related reactions.”

“Antibodies against infliximab cannot always be detected in serum samples.”

This might be based on European studies, or maybe we've stumbled upon a controversial topic in the world of rheumatology.

Good that you have more frequent bloodwork now – you might never get any blood abnormalities, but better safe than sorry. While my blood has never shown any side effects from my meds (knock on wood), I’m glad it is monitored closely.

How are you doing on Remicade nowadays?

I was on MTX for 2 months, getting no relief. My rheumy added Enbrel. I am now on MTX and Enbrel combo for 2 months. I feel 70% better and have mentioned to my rheumy on my last visit that I wanted to drop MTX because I think it's the Enbrel doing the job, not MTX. She said since I'm getting good response to the combo now, she didn't want to change the medication, risking another flare up. She said when I feel 100% pain free, then she will gradually take off MTX for me.

Olivia