A leading rheumatologist has put out a national call for GPs to embrace a shared care model to facilitate the early and sustained use of methotrextate in rheumatoid arthritis (RA).

Queensland rheumatologist and ARA board director Dr Claire Barrett has collaborated with NPS Medicine Wise to promote a model of care that promotes urgent referral to a rheumatologist and structured collaboration between rheumatologists, GPs and other health professional to encourage uptake of the ‘gold standard’ of treatment for RA.

Her article, which features in the latest NPS MedicineWise News, states that low-dose methotrexate is the recommended first-line DMARD for most patients with RA but needs to be commenced within the short 3-month window of opportunity to give patients best chance of reaching clinical remission.

The rationale behind the shared care model draws on Australian clinical experience and research that finds:

• Fears about toxicity drive down adherence rates to low dose methotrexate, with patients mistakenly believing they face the same risks as patients taking high doses as chemotherapy;
• This confusion is also deterring some from self-administering the drug at home because they are under the misapprehension that chemotherapy guidelines – which require administration by an oncology nurse using eye mask and gloves – apply to them;
• Many patients are staying on corticosteroids long-term where adverse effects are common;
• Patients who are referred to a specialist within 3 months of disease onset are more likely to experience drug-free remission, have less joint damage seen on X-ray, and have less need for orthopaedic surgery compared to patients referred at a later stage;
• Almost all rheumatologists regard pre-referral investigations as important but only 20% of GPs are doing them;
• Only a small percentage of patients with RA trial both oral and subcutaneous methotrexate before treatment is escalated. Educating patients about the potential benefits and correct administration procedure may increase efficacy and lead to lower incidence of adverse effects of subcutaneous methotrexate.

All patients with RA should have an action plan prepared with input from the rheumatologist and GP, says Dr Barrett. The plan should cover aspects of care including drug toxicity monitoring, reproductive health, vaccinations, infection monitoring, disease activity review, complications and how to deal with disease flares. 

“Guidelines for the GP on how to monitor low-dose methotrexate, and manage the patient, including when to refer back to the rheumatologist earlier than the planned review, are the best way to ensure safe use of methotrexate and optimal treatment results,’ says Dr Barrett.

“The use of DMARDs, with methotrexate as the backbone of the treatment, has revolutionised RA management, but there is still room to maximise the benefit,” she concludes.

The proposal is co-authored by Associate Professor Morton Rawlin, a Melbourne GP.