POS0227 SHOULD ALL PATIENTS TRIAL SUBCUTANEOUS METHOTREXATE PRIOR TO COMMENCING BIOLOGIC THERAPY – A REAL WORLD STUDY

Abstract

Background:Methotrexate (MTX) is the bed rock of inflammatory arthritis management. However intolerance is a major limiting factor for drug optimisation and retention. There is data to suggest that subcutaneous (SC) MTX is tolerated better and is now being recommended in several guidelines including ACR’s. It is less clear though whether this strategy is effective in those where oral preparation is inefficacious and its potential to avoid escalation to biologic therapy.Objectives:Our aim was to analyse the reasons for switching to SC formulation in a real world setting, clinical outcomes achieved and proportion requiring biologic prescription.Methods:We undertook a retrospective survey of all patients prescribed SC MTX in a large university teaching hospital between 1983 and Apr 2019. We had access to full patient records including details on co-morbidities, drugs and disease management. We analysed demographics, reasons for SC MTX initiation, clinical outcomes and impact on biologic prescription.Results:352 patients were identified during the study period. The mean age of the cohort was 54 yrs (3-87). 192 (70%) were women. 260 (74%) were Caucasian, 64 (18%) Asian, 21 (6%) Afro-Caribbean and remaining of other ethnicity. Two most common diagnoses were RA [n=243 (69%)] and pSpA [n=66 (18%)]. Average disease duration was 74 months (11-324) with mean of three comorbidities (0-11).284 (80%) had switched from oral to SC MTX. 137 (49%) stopped oral MTX due to side effects. Mean duration of oral MTX prior to switching was 26 months (0.25-167). Follow up period for SC MTX ranged from two to 132 months (mean 29) until the data cut-off date of Apr 2019. 103 (29%) patients progressed to biologic therapy.Amongst RA patients, DAS28 improved from mean 4.16 (0.63-8.06) to 2.83 (0.14-7.32) following the switch. pSpA cohort’s mean TJC and SJC improved from mean seven (0-42) and two (0-26) to two (0-25) and one (0-6) respectively.Conclusion:Our study confirms that SC MTX is an effective solution irrespective of whether oral MTX is inefficacious or intolerable. This applies to people with both RA and pSpA. In accordance with prior published data, our findings support the utility of SC MTX for those intolerant of enteral option. Additionally, it shows that even in instances where oral MTX was ineffective, a switch to SC formulation achieved low disease activity despite multi-morbidity, long disease course and protracted oral MTX exposure. This intervention also prevented over two-thirds of patients progressing to biologic therapy with significant financial savings. SC MTX therefore remains a durable strategy with excellent disease outcomes and confers substantial economic benefits to healthcare.Disclosure of Interests:None declared