Weekly oral methotrexate?

[Mandelin Rain]

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Hoping to get some thoughts, if not consensus on how people counsel their patients on oral MTX for non-oncologic issues like RA or Sarcoidosis.

Usually, I recommend bridging with steroids, but what about in the person who truly needs it.

 

[RADONC4285]

Hoping to get some thoughts, if not consensus on how people counsel their patients on oral MTX for non-oncologic issues like RA or Sarcoidosis.

Usually, I recommend bridging with steroids, but what about in the person who truly needs it.

What are you going to radiate? What dose? Usually have the rheumatologist stop or bridge with steroids, but if not at all possible you can consider concurrent treatment and counsel on potential for excess tox depending on above questions

 

[Mandelin Rain]

What are you going to radiate? What dose? Usually have the rheumatologist stop or bridge with steroids, but if not at all possible you can consider concurrent treatment and counsel on potential for excess tox depending on above questions

Breast and prostate are pretty classic ones. I think dose is usually 7.5-10 mg weekly for RA.

Current guy prompting question is a prostate on 12mg weekly for bad sarcoid.

 

[RADONC4285]

Breast and prostate are pretty classic ones. I think dose is usually 7.5-10 mg weekly for RA.

Current guy prompting question is a prostate on 12mg weekly for bad sarcoid.

If the patient is a good candidate and you have the capability, consider prostate SBRT or mono brachytherapy

 

[evilbooyaa]

I generally try to get the doc to stop and bridge with steroids as necessary. I have a H&N pt in a similar boat coming up that I need to have this discussion with the PCP who is managing the MTX.

Not at all enthusiastic to do concurrent chemo + RT with any MTX on board. Different scenario than prostate/breast, but just to have another data point.

 

[TheWallnerus]

Hoping to get some thoughts, if not consensus on how people counsel their patients on oral MTX for non-oncologic issues like RA or Sarcoidosis.

Usually, I recommend bridging with steroids, but what about in the person who truly needs it.

Refresh my memory: aren't RA and sarcoidosis MTX doses 1-2% (or less) the dose of MTX in anti-neoplastic therapy (>500mg/m/m in as little as 24h period). If MTX at anti-neoplastic therapy doses would augment RT effects by up to ~10-20%, then MTX at RA doses might augment RT effects by 0.1-0.2%? AFAIK there's no great data on low-dose MTX and RT being bad, or good. Although there's data of course to suggest RA is not a contra-indication to RT.

Remember when people used to freak out that you couldn't vaccinate someone while undergoing RT? It was unsafe etc, or made vaccines not work. I'm prepared to rate being fearful about low-dose MTX and RT as oncolore. But open to be convinced otherwise... with data.

EDIT: MD Anderson... "In general, vaccines aren’t recommended during chemotherapy or radiation therapy." Lol. 2017.

 

[Brim]

I haven't stopped MTX in nearly all cases and patients have tolerated RT well. Might consider holding it if irradiating a large field or a lot of bowel.

 

[Palex80]

One of my prostate cancer patients on methotrexate developed obstructive symptoms and accumulated methotrexate a few weeks after completing radiotherapy (he didn't stop talking the pills), leading to severe pancytopenia with complications requiring hospitalization.

And yes, I do feel very bad about it.

 

[TheWallnerus]

One of my prostate cancer patients on methotrexate developed obstructive symptoms and accumulated methotrexate a few weeks after completing radiotherapy (he didn't stop talking the pills), leading to severe pancytopenia with complications requiring hospitalization.

And yes, I do feel very bad about it.

Are you saying he wasn't peeing enough methotrexate out after RT because the RT gave him obstructive problems? Then we need to have MTX stopped for how long after completing RT. This could be a problem with numerous (renally cleared) type drugs: prostate RT causing drug accumulation. If a person seeing a urologist for BPH and who has RA, I wonder if the urologists try to stop MTX.

 

[Palex80]

Are you saying he wasn't peeing enough methotrexate out after RT because the RT gave him obstructive problems? Then we need to have MTX stopped for how long after completing RT. This could be a problem with numerous (renally cleared) type drugs: prostate RT causing drug accumulation. If a person seeing a urologist for BPH and who has RA, I wonder if the urologists try to stop MTX.

He had trouble peeing and also not drinking enough, because he had trouble peeing. 🙂 Additionally it was summer and quite hot.
So he had a pre- and post-renal component for a renal dyfuncton which led to an accumulation of methotrexate.

 

[TheWallnerus]

He had trouble peeing and also not drinking enough, because he had trouble peeing. 🙂 Additionally it was summer and quite hot.
So he had a pre- and post-renal component for a renal dyfuncton which led to an accumulation of methotrexate.

So maybe (MTX+RT = disaster) ≠ truth

 

[Palex80]

So maybe (MTX+RT = disaster) ≠ truth

I do think that I (RT) caused a sizable part of that post-renal component (ok, his prostate wasn't tiny).