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Nocebo effects in practice: methotrexate myths and misconceptions

Providing patients with accurate information will help overcome obstacles to the use of an effective treatment for rheumatoid arthritis

Weekly low dose methotrexate is the first-line agent and arguably an essential disease-modifying antirheumatic drug (DMARD) in the treatment of rheumatoid arthritis (RA).1 Australian rheumatologists’ practice mirrors the recommendations of international rheumatology associations24 for early treatment with methotrexate, often combined with other DMARDs. A trial of methotrexate in combination with other DMARDs is an Australian prerequisite for therapy with biological disease-modifying drugs. About 20% of more than 3.4 million Pharmaceutical Benefits Scheme-subsidised DMARD prescriptions issued between 2003 and 2007 to 236 000 Australians for the treatment of RA were for methotrexate.5 As older agents such as injectable gold, azathioprine and cyclosporine fall out of favour, methotrexate usage will likely increase, not only for treatment of RA but also other rheumatological and inflammatory conditions such as psoriatic arthritis, juvenile idiopathic arthritis and systemic vasculitis.

Knowledge of the pharmacology of methotrexate is important to understand its potential toxicity. The inter-individual bioavailability of oral methotrexate…