How does a Rheumatologist determine which meds to prescribe?

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I was diagnosed with RA at the end of April.  Apparently my condition is relatively mild – I hope so!  My Rheumatologist initially put me on SALAZOPYRIN which I reacted badly too.  I am now 2 weeks in to taking METHOTREXATE (12mg weekly) a small dose and obviously this has not had time to take effect yet. 

How does a Rheumatologist determine which meds to prescribe?  There are so many out there and the side effects all vary to a degree.  I hate the thought of putting something so toxic in my body.  Is it literally just  a case of trial and error?  For instance most feedback back regarding consuming alcohol while taking METHOTREXATE is to avoid yet my RT knows I enjoy a glass of wine (or 3) & is happy for me to do so? Also I am in my mid-thirties & relatively newly married if I want to conceive I have to allow 3 months of being off this before trying surely at my age it would make sense to prescribe me something that wouldn’t be a problem if I did get pregnant.  I would have to go through the pain & frustration of adjusting to something new.  I know I have to trust he knows what he is doing but it’s frustrating.  We are currently UK expats in the middle east so the language barrier doesn’t help!  Being new to RA any feedback and knowledge would be much appreciated.

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  • Posted

    In the UK there is a list of drugs appropriate for the management of RA, at the top are the least expensive DMARDs (Disease Modifying AntiRheumatic drugs) and at the bottom the much more expensive biologics. In the UK they commonly start at the top with methotrexate which has been in use for years and works for many patients unless there is any medical reason not to. They start at the beginning and work down, not just on cost grounds but also because not all drugs work for all patients and sometimes they may work for a time and then stop being so effective - so you don't go straight to the heavyweights at first for obvious reasons. In that sense it does have an element of trial and error to find the drug that works for you to manage the symptoms best and with the most tolerable side effects for you.

    There are other drugs that can't be used during conception/pregnancy so they usually ignore that aspect until you say you now want to try to start a family. Most rheumies are realistic enough to allow the odd glass of something but it really isn't a good idea to drink much on it - your liver won't like you for it and that may stop you taking mtx too.

    As for putting something toxic in your body - I'm afraid that is the way the drugs work and the alternative is to suffer the disease. Which really isn't much of an alternative.

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  • Posted

    I do empathise with you and especially so when there is a language difficulty added. Eileen is right, they usually try you on DMARDS first then if not helping move onto the biologics. Either way I wouldnt want to be taking them and getting pregnant. I think you either have to think about pregnancy or drugs right now and talk to your Rheumo about that. The ŔA society website can help with appropriate research papers too. Even strong anti inflammatories may be inappropriate in early pregnancy I would think. Maybe you need to be well and your inflammatory disease at least under control before you do anything else. Is there a chance of returning to uk for a private consultation with a rheumo with your bloodwork with you? Its a dilemma for sure, I wish you all the best for your future. Autoimmune disease us a nasty business and nit to be taken lightly, though at keast not life threatening. ...the onky plus point!

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  • Posted


       Sorry you are having to deal with this and in a country with language barrier issues on top of that

       I am in the US and the gold standard treatment here initially is methotrexate and if not tolerated then the other DMARDS as someone else has written on the forum.  I think it also depends on personal preference of the doc--what they have found to be successful in treating RA individuals.  Insurance is also a factor honestly in the US.   My insurance will pay for biologic in addition to help from the manfacturer of the drug for a period of time. But once I lose that insurance it will be back to DMARDs.

       It's unfortunate but it's trial and error with the drugs and how ea. person tolerates and if it helps or is not effective.  Hopefully the doc knows your plans for becoming pregnant sometime in the future. And will advise you.

        While I was on MTX my RA doc did say I could drink wine in moderation but it is not really advised with concerns of liver damage.     


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  • Posted

    MTX is considered the gold standard for RA, rheumo's words, and has been my drug of choice, not mine I hated the idea of taking such a toxic drug, but it works and my liver tolerates just, the drug.

    As my RA is so intractable, it does not improve or very little, she has tried leflunomide or arava, starting with 10mg which I deal with quite well, 20mg only gives me extremely high and dangerous blood pressure, which really shocked her and the drug company, I am such a tiny amount of the general population, to have that reaction.

    Last  bloods were ESR 77, and CRP 37, which are very high numbers for me, and in alot of pain in shoulders and chest, as the GP told me too all intents and purposes you would be considered to be having a heart issue if we didn't know about your arthritis, and the problem is only a blood test and ECG would tell us if you were.

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  • Posted

    Purely and simply - guesswork!
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