The Journal of
`
`Rheumatology
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`The Journal of Rheumatology
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`Volume 28, no. 1
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`Self-injection of gold and methotrexate.
`
`V Arthur, R Jubb and D Homer
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`J Rheumatol 2001;28;212
` http://www.jrheum.org/content/28/1/212.1.citation
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`The Journal of Rheumatology
` is a monthly international serial edited by Earl D.
`Silverman featuring research articles on clinical subjects from scientists working in
`rheumatology and related fields.
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`Downloaded from Downloaded from www.jrheum.orgwww.jrheum.org The Journal of on October 1, 2015 - Published by The Journal of on October 1, 2015 - Published by
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`in respect of pain, fatigue, early morning stiffness, and Lender joints.
`Erythrocyte sedimentation rate and C-reactive protein levels fluctuated slight(cid:173)
`ly as would normally occur. No difficulties were encountered with selr(cid:173)
`administralion. One patient experienced a transient local reaction around the
`injection site. All participants were satisfied with the teaching procedure.
`Patiems preferred the sc route of administration as ii was less painful ancl per(cid:173)
`mitted !hem to self-inject.
`Jt would appear that self-administration of'sc MTX is n safe nncl effective
`procedure for patients with reasonable dexterity. As n result of' this study, we
`have changed our practice with the development and adoption of' a new pro(cid:173)
`tocol. Patients arc given MTX by the sc route rather than the im, those that
`are willing are laugh! to self-administer and encouraged to undertake this pro(cid:173)
`cedure at home. Weekly hospital visits have been reduced Lo monthly with
`benefit lo patiems in terms or cost, time, and convenience.
`
`University Hospital,
`Birmingham, UK.
`
`Valerie Arthur, RN. MPhil;
`Ronald Jubb, MD, rRCP;
`Dawn Homer, RN.
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`REFERENCES
`l. Arthur AB, Klinkhoff AV, Teufel A. Safety of self-injection of gold
`and methotrexate. J Rheumatol l 999;26:302-5.
`2. Lourdes M, Montserrat R, Rozadilla A, Cintero Ml. Evaluating the
`safety and self-injection of' gold and metholrexate in patients with
`inflammatory arthritis fletter]. J Rheumatol 2000;27:8 l 8.
`3. Brookes PJ, Spruill WJ, Prish RC, Birchmore DA.
`Pharmacokinetics of methotrexate administered by intramuscular
`and subcutaneous injections in patients with rheumatoid arthritis.
`Arthritis Rheum 1990;33:91-5.
`4. Jundt JW, Browne B, Fiocco GP, Steele AD, Mock DA. A
`comparison of low dose methotrexate bioavailability: oral solution,
`oral tablet, subcutaneous and intramuscular dosing. J Rheumatol
`1993 ;20: 1845-9.
`
`Dr. Klinkhoff, et al reply
`To the Editor:
`
`The team from Birmingham are to be commended for piloting a self-injection
`program for methotrexate (MTX). While 8 patients is a small sample to deter(cid:173)
`mine preferences and safety, their conclusions are similar to our own. We
`have employed a successful self-injection program for gold and MTX for 5
`years. Patients are taught either intramuscular or subcutaneous injection tech(cid:173)
`nique. We have encountered no serious problems after routine use of self(cid:173)
`injection or partner irtjection for years in more than I 00 patients. Because of
`the high incidence of annoying and potentially dangerous side effects that
`require close supervision, we have targeted for self-injection education those
`arthritis patients who are stable taking injectable medication and who Jmve
`no! encountered any potentially serious adverse events over a followup peri(cid:173)
`od of 6 months.
`
`Mary Pack Arthritis Cemre,
`Vancouver, Cmmda.
`
`Alice Y. Klinkhoff, MD. rRCl'C;
`Anne B. Arthur, RN;
`Alvena Teufel, RN.
`
`Radiographic Diagnosis of Sacroiliitis -Are Sacroiliac Views
`Really Better?
`Ji, the Editor:
`
`Readers were invited lo comment on Figure l of page 2713 of the December
`l 999 issue of 7'l1e .lo11mal'. Like Dr. McDuffie we are pre!ly experienced
`rheunmtologisls, but we must admit !ha! we are often in doubt about the diag(cid:173)
`nosis of sacroiliitis on rndiographs. ln these cases, like McDuffie, we order n
`computer tomography (CT) scan. However, we disagree when he writes that
`
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`
`Self-Injection of Gold and Methotrexate
`To the Editor:
`
`We read with interest the paper by Arthur, et al' and the correspondence relat(cid:173)
`ing to ii'. We recently completed a small, pragmatic study to compare the
`safety and efficacy of methotrexate (MTX) administered by 2 different routes,
`intramuscular (im) and subcutaneous (sc), and to teach patients to self-admin(cid:173)
`ister MTX by the subcutaneous route. A literature search produced little evi(cid:173)
`dence about the bioavailability of MTX between the 2 parenteral routes'" and
`nothing relating to the safety of patient administration. We recognized that
`there could be potential advantages in terms of convenience, cost, and active
`patient involvement.
`Eight patients receiving a stable weekly dose of intramuscular MTX,
`who attended the nurse specialist clinics, were invited to participate in the
`study. Of the 8 participants, 6 were female and 2 were male. The mean age
`was 43 years (range 36-58). Four had rheumatoid arthritis, 2 psoriatic
`arthritis, one Wegener's granulomatosis, and one polymyositis. The mean
`disease duration was 11 years 4 months.
`The study was undertaken over 13 weeks. At week l variables of disease
`activity were measured. The nurse specialists administered weekly im MTX
`al weeks l to 3. Serum levels of MTX were measured 1 h after the 3 injec(cid:173)
`tions. Al week 4 the route of administration was switched to subcutaneous.
`The nurse specialists administered weekly sc MTX al weeks 4 to 6. Serum
`leveb of MTX were measured I h al'!er these. Patients were taught during this
`phase by practical demonstration and with the addition of written information.
`For weeks 7 to 9 patients administered their own MTX by sc injection under
`the supervision of the nurse specialists. Al week 9 patients were discharged to
`sell~adminisler the injections al home. They were provided with pre-drawn
`syringes, gloves, needles, swabs, sharps disposal boxes, and spillage kits.
`They had the backup facility of the rheumatology nurses' telephone help-line.
`The participants self-administered the MTX at home for weeks l O lo 12.
`At week 13 they relnrned Lo the nurse specialist clinic. At this visit variables
`of disease activity and patient satisfaction were assessed. Safety monitoring
`was undertaken for MTX therapy and patients were observed administering
`their own injections to ensure that their technique was still correct. Used
`sharps boxes were returned and new supplies were provided. A further
`appointment for one month was given.
`The results from this study have shown that there was no significant dif(cid:173)
`ference between sc and im MTX. Individual patients had serum levels of
`MTX that ranged from 0.34-J.56 mm/I. TJ{erc wan10 significant difference
`
`212
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