Should All Patients Trial Subcutaneous Methotrexate Prior to Commencing Biologic Therapy? A Real World Study.

Introduction: Methotrexate (MTX) is the bed rock of inflammatory arthritis management. However, intolerance is a limiting factor for drug optimisation and retention. There is data to suggest subcutaneous (SC) MTX is better tolerated. It is less clear whether this strategy is effective in those where the oral preparation is inefficacious and its potential to avoid escalation to biologic therapy. Objectives: To analyse the reasons for switching to SC MTX in a real-world setting, clinical outcomes achieved and proportion requiring biologic prescription. Materials and Methods: A retrospective survey of patients prescribed SC MTX in a university teaching hospital identified 352 patients. 298 switched from oral to SC MTX- 164 stopped oral MTX due to side effects, 134 stopped due to inefficacy, and 54 started SC MTX as first line therapy. 103 patients progressed to biologic therapy. Rheumatoid arthritis (RA): DAS-28 improved from a mean of 4.06 (0.63-8.06) to 2.83 (0.14-7.32) following the switch (p<0.0001). Psoriatic arthritis (PsA): total joint count improved from a mean of 7 (0-42) to 2 (0-25) (p<0.0001). Swollen joint count improved from a mean of 2 (0-26) to 1 (0-6) (p=0.09). Discussion: SC MTX is an effective solution for RA and PsA, irrespective of whether oral MTX is inefficacious or intolerable. Where oral MTX was ineffective, a switch to SC achieved low disease activity despite multi-morbidity, long disease course and protracted oral MTX exposure. This intervention prevented over two-thirds of patients requiring biologics. SC MTX is a durable strategy with excellent disease outcomes and substantial economic benefits.

Men and women's perceptions of hot flushes within social situations: are menopausal women's negative beliefs valid?

OBJECTIVES: Menopause is generally associated with negative social meanings in western cultures. While numerous physical and emotional symptoms have been attributed to it, hot flushes and night sweats (HF/NS) are the main physical change. Recent studies suggest that cognitive factors, particularly beliefs about other people's reactions to their HF/NS, might increase distress, causing embarrassment and behavioural avoidance. Younger men and women tend to have more negative attitudes to menopause but research is needed to establish whether menopausal women's beliefs are grounded in evidence or are overly negative cognitions. METHODS: 290 men and women (aged 25-45 years) participated in a questionnaire survey, including both qualitative and quantitative data. Participants answered open-ended questions about their attributions and reactions to a hypothetical scenario of a woman displaying hot flush symptoms and completed a modified version of the Menopause Representations Questionnaire (MRQ) to assess beliefs about menopause. RESULTS: A wide range of attributions and responses were evident. The majority of participants did not attribute redness and sweating to the menopause; similarly mainly neutral and positive responses were expressed. However, this younger sample had significantly more negative beliefs about menopause (MRQ) compared to a sample of menopausal women and women identified more symptoms as being due to the menopause than men. No age differences were evident. CONCLUSIONS: These findings suggest that women's beliefs about 'other people's' reactions are unduly negative. This evidence can be used in cognitive behavioural interventions to help women to challenge these beliefs and behaviours that exacerbate distress.