Medication

Taking your medication

Time to effect

Most disease-modifying medications (DMARDs) take 8-12 weeks to be effective, particularly if they require a gradual dose increase. Some people notice an improvement earlier than this.

When to take medication

Some medication needs to be taken on an empty stomach or separately from other drugs. If this is the case we will tell you when the treatment is first prescribed. Full instructions are clearly stated on the packaging or accompanying leaflet.

Some medication such as anti-inflammatory (NSAID) drugs should always be taken with or immediately after food. Again, this should be clearly stated on the drug packaging.

Methotrexate is only to be taken once weekly, on the same day each week.

It is important to take all medication at the correct dose and at regular intervals as recommended.

Before surgery

Depending upon the reason for your admission, we may advise you to temporarily stop some or all of your treatment. However, you should continue to take all prescribed medication unless specifically advised to do otherwise.

Biologic treatment may need to be stopped for one to two weeks before surgery, and can usually restart one to two weeks after surgery, once the wound is healed and you are free of infections.

Before dental treatment

We recommend that you continue on your medication when having dental treatment.

How long to continue on medication

Most patients stay on their medication for a number of years. The aim of treatment is to get the condition into remission, which means a significant reduction in the symptoms of inflammation, but it doesn't necessarily mean that the condition has gone.

The more aggressively we treat inflammatory arthritis at presentation, the more likely we are to achieve and maintain remission.

Not everyone will be able to stop their medication, but most should be able to reduce the dose and number of drugs they take once their disease is under control. We will aim to ultimately get you on the minimum amount of medication to keep you well.

With any chronic inflammatory condition flares may occur and should not be seen as a sign of treatment failure, though if your flares increase in frequency or severity we will need to adjust or escalate your treatment.

Alcohol

Some medicines used to treat your arthritis are processed by your liver, and when taken with alcohol can increase the risk of liver side-effects.

We recommend that you have no more than 10 units of alcohol a week.

Methotrexate

NSAIDs / aspirin and Methotrexate

Methotrexate can theoretically interact with anti-inflammatory drugs including aspirin.
This is not a concern with the dosages of Methotrexate prescribed for the treatment of arthritis.

However, long-term anti-inflammatory use is associated with an increased risk of gastric, kidney and cardiovascular problems and if at all possible should be avoided.

Folic acid and Methotrexate

Methotrexate may be associated with side-effects such as mouth ulcers, and these can be reduced or improved with folic acid.

Side-effects

Unfortunately some medications used to treat rheumatic diseases can cause side effects such as:

• nausea
• diarrhoea
• vomiting
• headache
• dizziness
• mouth ulcers
• sore throats
• rashes.

Rarely, patients can develop shortness of breath and/or a dry cough, which may require further investigation.

It is important to report any side-effects, even if not listed above, and seek advice from your GP or the Rheumatology team about continuing treatment.

Nausea

Feeling sick (nausea) is a common side-effect of Methotrexate, especially when treatment starts. This normally gets better, but for some people it may continue.

This feeling may be helped by:

• taking the methotrexate with or after food
  
• taking the methotrexate just before you go to bed; you may be able to sleep through the feeling of sickness
  
• making sure you take your folic acid
  
• switching to injectable methotrexate.

Sometimes the dose of folic acid can be changed, but this should only be done after speaking to a doctor. Your doctor may tell you to take another tablet to reduce the feeling of sickness. The Rheumatology team may also change your Methotrexate tablets to an injection once a week.

It is important that you take your Methotrexate regularly so do not stop the drug without discussing it with the Rheumatology team or your doctor first.

Diarrhoea and vomiting

If you are vomiting and unable to keep food down, it is sensible to omit your rheumatology medication while symptoms persist. When things have settled, start taking your medication again: however, if symptoms come back, then the symptoms may be due to the treatment, please email us.

Email: rheumatologyadviceline@ouh.nhs.uk

If you are taking Methotrexate in tablet form, it may be possible to change this to the injectable preparation. This is given under the skin, bypassing the gastrointestinal system, so less likely to cause side-effects such as nausea, vomiting and diarrhoea. If you would prefer this, please discuss with the Rheumatology team at your next appointment.

Injection site reactions

Injection site reactions include redness, itching, pain or swelling at the injection site. They mostly occur one to two days after an injection and go away within three to five days. They are most common during the first few months of treatment.

It may help to apply a cold compress to the site. Antihistamine tablets or creams available from your chemist can help.

Injection site reactions can be due to the way an injection has been given. Try changing where you give the injection each time: you can inject into the front of the thigh and abdomen.

If you have pain, redness, or swelling around the injection site that doesn't go away, or gets worse, please email us at the address given above.

If you keep having problems with reaction, we may need to check the way you are doing the injection.

Holidays / travel

You need to take your medication with you, including any injections you need, when you go on holiday.

If you get your prescription from your GP, please get in touch with them in good time to request extra medication for when you are on holiday.

If we supply your medication, please contact us for a travel letter if you are taking injections with you on a plane.

Keep your medication in your hand luggage if you are flying.

Missed injections (Methotrexate or biologic therapies)

Ideally your medication schedule should not be interrupted as this increases the risk of your condition flaring.

If you have weekly Methotrexate injections, it may be possible to have a small supply of tablets prescribed for you to use instead during your holiday, but this is not an option if you have previously been intolerant of these.

People who regularly self-inject biologics drugs such as Etanercept (Enbrel) or Adalimumab (Humira) may continue while away, but ensure that refrigeration facilities are available.

Before you go, make sure you have sufficient supplies of your medication and 'sharps' bins for disposal of used syringes. Request a holiday letter from the delivery company or Rheumatology team to have with you when taking injectable medication through customs.

Missed routine blood monitoring tests

Obviously it may not be practical for you to arrange blood monitoring tests if you are away from home. Where possible, schedule tests for a week or so before your departure and as soon as possible after your return.

If you are planning an extended trip please discuss this with your GP, as alternative arrangements may need to be made.

Interactions with other medication

Over-the-counter pain medication

Always check over-the-counter medications for possible interactions with prescribed drugs.

Simple painkillers such as paracetamol are usually safe, providing you do not exceed the maximum recommended dose and ensure that none of your prescribed drugs also contain paracetamol, since this could result in accidental overdose.

Do not take over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as Nurofen if you are already taking prescribed NSAIDs. Avoid NSAIDs if you have previously suffered any adverse effects or have a history of gastritis or stomach ulcers.

Also avoid NSAIDs if you are asthmatic or have high blood pressure unless your GP advises you to take them.

Other prescribed medications

Bring a list of all your medications with you to every appointment: we take all your medications into account when making prescribing decisions.

Complementary / herbal remedies

Complementary or herbal medicines may interact with prescribed drugs. If you wish to use these therapies, please discuss this with us at your appointment.

Prescription and delivery

Expired prescriptions

Your doctor will receive a letter regarding any changes to your treatment made in clinic and can renew your prescription.

Biologic drugs are the exception and are only prescribed by the Rheumatology team. You will need to attend your clinic appointments for us to be able to do this. The prescription is then managed with the delivery company.

Deliveries

Your prescription is managed by the Rheumatology nurses in conjunction with the delivery company. Usually the delivery company asks the nurses for your repeat prescription to be renewed well before it is going to expire but occasionally this does not happen in time.

The Rheumatology nurses will renew your repeat prescription if you have attended your scheduled clinic appointments and had any relevant bloods or tests that have been asked for.

If you do not attend your appointments, your prescription for biologic drugs will be stopped. You may need to call the Rheumatology nurses to discuss your repeat prescription.

Drugs not delivered

Please contact the company that delivers your medications to reorganise the delivery.

You may ask to have medications delivered to you at work, or an alternative address, to make things easier, but do ensure that there is refrigeration available.

If you have ongoing delivery problems cannot solve yourself with the company, please contact the Rheumatology nurses.

Blood tests

We monitor bloods when DMARDs and biologic medicines are used. This is to ensure that the drugs are being used safely and not causing any harmful effects.

Blood tests we commonly monitor

• Hb (Haemoglobin)
  The iron-rich molecule of red blood cells which transport oxygen around the body.
  Normal values for a man are 130-180.
  Normal levels for a woman are 115-165.
• MCV (Mean Cell Volume)
  A measurement of the average volume of red blood cells (this can vary if you have low iron stores or if you have pernicious anaemia).
  Normal values 82.0-98.0.
• WCC (White Cell Count)
  Blood cells of the immune system. There are five types and this reflects the total number of all types.
  Normal values 3.6-11.
• Neutrophils
  One of the white blood cells important in fighting bacterial infections. This can be affected by inflammation and medications.
  Normal values 3.6-7.5.
  
• Lymphocytes
  White blood cells important in fighting viral infections.
  Normal values are 1.0-4.0.
• Platelets
  Blood cells involved in maintaining blood clotting.
  Normal values are 140-440.
• ALT (Alanine Transaminase)
  A liver enzyme that reflects liver health.
  Normal value is less than 40.
• Creatinine
  The level of creatinine in the blood is an indicator of how well the kidneys are working.
  Normal value is 59-104.
• CRP (c-Reactive Protein)
  A protein that measures levels of inflammation. It is helpful in guiding how active your disease is and whether your treatment is effective, but it is non-specific, and may rise for other reasons such as infections or viruses.
  A normal level is less than 8.
  Patients who are overweight often have a higher baseline CRP and in the absence of any inflammation or infection levels can range from 10-20.

It is important to note that all blood values will fluctuate slightly through the day and you may see in your blood monitoring booklet that occasionally blood values fall outside of the normal range. Often this is not a matter of concern.

Should there be any cause for concern, the GP who reviews all blood tests as a part of blood monitoring will contact you with appropriate advice. The GP will contact the Rheumatology team if they have ongoing concerns.

Yellow shared care blood monitoring cards

If you need a new yellow shared care blood monitoring card please contact us and we will send you another in the post.

Tel: 01865 737871