Rheumatology Vol. 44 No. 2 ß British Society for Rheumatology 2005; all rights reserved
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`256
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`Letters to the Editor
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`keeping with their consultation, 98% understood all/most of the
`letter, and 100% found it useful or very useful [3].
`The benefits of sending copy letters to rheumatology patients
`have been known for nearly 20 yr [4]. Several subsequent studies
`from oncology, paediatrics and primary care in the 1990s showed
`a generally positive response from patients [5, 6]. Despite the
`overwhelming evidence that patients want copy letters, the practice
`has been slow to take off. The Department of Health guidelines
`and changing attitudes among health-care professionals may
`make a difference. McConnell et al. investigated the opinions
`and practice of provision of audiotapes and letters by surgeons,
`oncologists and GPs [7]. They found that younger clinicians were
`more likely to make information from the consultation available
`to patients, which may reflect changes in emphasis in medical
`education.
`There are some drawbacks to copying letters. There is an
`increased secretarial workload and administrative cost. Our survey
`suggests that secretaries are supportive of the process. A pilot study
`in 2002 in a Northeast GP surgery found that the cost of each letter
`was around £1, with a cost to the practice of £5000 per annum [8].
`However, the study by Tomkins et al. in a dermatology department
`found the cost to be 25.3 pence per patient: 2 pence in paper and
`printing, 1 pence for the envelope, 19 pence in postage and 3.3
`pence in secretarial time [3]. They felt the cost to be small in
`comparison with the benefits gained. If copying letters can improve
`compliance, hospital attendance and reduce the need for follow-up
`appointments, costs overall may be reduced, but this is yet to be
`proven.
`One of the other issues is the communication of sensitive issues.
`Two specialties where this is most relevant are oncology and
`psychiatry. A Cochrane review found that between 83 and 96%
`of patients found recordings or summaries of their oncology
`consultations valuable [9]. Although patients with cancer found
`receiving the letter distressing to some extent, they still thought it
`was useful [6]. Nandhra et al. conducted a study on 76 psychiatry
`patients and found that 83% of the patients wished to continue to
`receive letters, and most found it helpful to receive letters despite
`18% finding the letters distressing [10].
`Our survey confirms that patients want to receive copy letters
`and find it very useful. The beneficial effects outweigh the
`drawbacks, which can easily be overcome. We suggest that the
`benefits of copying letters should be recognized and the process
`welcomed voluntarily rather than eventually responding to an
`imposed compulsory directive.
`
`The authors have declared no conflicts of interest.1
`
`J. NIXON, P. COURTNEY
`
`Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB
`Accepted 5 October 2004
`Correspondence to: J. Nixon. E-mail:
`nhs.uk
`
`jnixon1@ncht.trent.
`
`1. Department of Health 2000. The NHS plan. Paragraph 10.3.
`London: Stationery Office. (www.doh.gov.uk/patientletters/)
`2. Ley P. Memory for medical
`information. Br J Soc Clin Pyschol
`1979;18:245–55.
`3. Tomkins CS, Braid JJ, Williams HC. Do dermatology outpatients
`value a copy of the letter sent to their general practitioner? In what
`way and at what cost? Clin Exp Dermatol 200;29:86–6.
`4. Gill MW, Scott DL. Can patients benefit from reading copies of
`their doctors’ letters about them? BMJ 1986;293:1278–9.
`5. Cowper DM, Lenton SW. Letter writing to parents following
`paediatric outpatient consultation: a survey of patient and GP views.
`Child Care Health Dev 1996;22:303–10.
`6. Damian D, Tattersall MH. Letters to patients: improving commu-
`nication in cancer care. Lancet 1991;338:923–5.
`
`7. McConnell D, Butow PN, Tattersall MH. Audiotapes and letters to
`patients: the practice and views of oncologists, surgeons and general
`practitioners. Br J Cancer 1999;79:1782–8.
`8. Jelley D, Walker C. Shouldn’t everyone know what is being written
`about them? Copying letters to patients. A pilot study in Northeast
`England, 2002. (www.doh.gov.uk/patientletters/).
`9. Scott JT, Harmsen M, Prictor MJ, Entwistle VA, Sowden AJ, Watt I.
`Recordings or summaries of consultations for people with cancer
`(Cochrane Review). Cochrane Library, Issue 3, 2004. Chichester,
`UK.
`10. Nandhra HS, Murray GK, Hymas N, Hunt N. Medical records:
`doctors’ and patients’ experiences of copying letters to patients.
`Psychiatr Bull 2004;28:40–2.
`
`Rheumatology 2005;44:256–257
`doi:10.1093/rheumatology/keh471
`Advance Access publication 5 January 2005
`
`Caveats to the use of parenteral methotrexate in the
`treatment of rheumatic disease
`
`SIR, methotrexate (MTX) remains the most widely prescribed of
`the disease-modifying anti-rheumatic drugs (DMARDs), but its
`clinical benefit is limited by gastrointestinal side-effects and a
`marked inter-individual variability in efficacy [1]. Parenterally
`administered MTX produces higher serum concentrations and
`more complete absorption than the orally administered drug at
`the top end of the dose range [2]. A recent open prospective
`study suggested improved efficacy with no reduction in safety on
`switching from oral to intramuscular (i.m.) administration in
`patients with active rheumatoid arthritis [3]. The parenteral route
`is well tolerated and there are no significant differences in bio-
`availability between MTX administered subcutaneously and
`I.M., making the two routes interchangeable [4]. On the downside,
`parenteral MTX costs more than seven times [5] as much as the
`oral preparation even before one takes associated expenses such as
`equipment, nurse and clinic time into account. It is imperative,
`therefore, that all reasonable steps are taken to ensure that patients
`are given an adequate trial of the oral drug before switching to the
`parenteral form.
`We analysed the notes of 102 of the 115 patients receiving
`parenteral MTX for a variety of conditions in the 3 months leading
`up to and including June 2002. Ninety-one patients were using the
`subcutaneous as opposed to the i.m. route and of these, 77 had
`successfully been taught to self-inject.
`All of the patients had received oral MTX prior to being
`switched and all had been receiving the parenteral drug for at least
`3 months (mean duration 22.9 months). We documented the
`reasons prompting the switch and whether or not appropriate
`alternative measures had been tried beforehand. Each patient’s
`perception of the ‘efficacy’ and ‘tolerability’ of the parenteral as
`compared with the oral preparation was gleaned from the notes, in
`clinic or over the telephone. A simple three-point scale was used:
`‘no difference’, ‘better’ and ‘worse’. The erythrocyte sedimentation
`rate (ESR) (mean of three) was noted in the 3 weeks prior to the
`switch and at the time of analysis. The same three-point scale was
`used, with ‘better’ being defined as a 20% fall and ‘worse’ as a 20%
`rise in the baseline ESR. Disease control measures employed
`subsequent to switching, such as corticosteroid administration
`(via any route), were recorded.
`Prior to switching, patients had taken oral MTX for a mean
`duration of 30.35 months (range 3 to 135 months). Of the 44
`patients (43.1%) switched purely due to lack of efficacy, only 27
`(61.4%) had received an oral dose of 17.5 mg/week or higher.
`Twenty-one of the 44 (47.7%) said they ‘felt better’ on the equi-
`valent parenteral dose and the same number noticed no change.
`There was an improvement in the mean ESR in 32 of the 44
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`Rheumatology Vol. 44 No. 2 ß British Society for Rheumatology 2005; all rights reserved
`
`Downloaded from
`
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`
`Letters to the Editor
`
`257
`
`Rheumatology 2005;44:257–258
`doi:10.1093/rheumatology/keh442
`Advance Access publication 5 January 2005
`
`Use of intravenous cyclophosphamide in the prevention
`of corneal melt: justified or not?
`
`SIR, Peripheral ulcerative keratitis (PUK), or corneal melt, is an
`aggressive destructive or necrotizing ulceration of the peripheral
`cornea presumed to be due to a microangiopathic vasculitis. It can
`occur following surgery that involves the cornea or sclera. It
`can lead to rapid (hours to days) corneal melting (keratolysis),
`perforation and eventual complete visual
`loss. Importantly,
`it
`heralds the onset of a systemic vasculitis in more than 50% of cases
`and is associated with a high mortality [1].
`PUK poses a significant problem in patients with rheumatoid
`arthritis (RA) undergoing surgery on the anterior segment of the
`eye, such as cataract surgery. Messmer et al. [2] reported that the
`development of necrotizing scleritis or PUK was associated with
`prior cataract surgery in 31% of their study population. They
`suggested special vigilance should be exercised in these patients
`postoperatively for 12 months and those patients with high risk
`should be immunosuppressed prior to surgery. Unfortunately,
`once PUK has developed, its treatment after cataract surgery has a
`poor ocular prognosis, despite immunosuppression and surgery,
`and the results are devastating (Fig. 1).
`We have successfully used intravenous cyclophosphamide in
`two cases as prophylactic therapy prior to cataract surgery. These
`two cases were considered to have high risk of developing PUK
`in that both had previously lost the sight in one eye due to PUK
`and required cataract surgery in the remaining eye.
`Case 1 was a 47-yr-old Caucasian lady with a 30-yr history
`of seropositive erosive RA controlled with D-penicillamine. She
`underwent routine cataract surgery in January 1995. There was
`no previous history of ocular or extra-articular manifestations
`of her disease. Unfortunately, she developed post-surgical PUK,
`eventually resulting in loss of vision. Her rheumatoid disease
`remained quiescent over the following 2 yr but she then developed
`a dense cataract in the remaining left eye.
`On this occasion she was prophylactically pulsed with intra-
`venous cyclophosphamide. This was given over a 6-month period;
`she received 1 g monthly 3 months prior to surgery and 3 months
`after surgery.
`Case 2 was a 72-yr-old Caucasian lady with a 40-yr history of
`nodular, seropositive RA with associated Sjo¨ gren’s syndrome. She
`had been treated previously with various second-line therapies
`and then maintained on oral prednisolone (2.5 mg). In 1993 she
`presented with a painful inflamed left eye consistent with PUK,
`which was treated with local therapy. This failed to respond,
`necessitating a corneal tectonic transplantation. No systemic
`therapy was given and her eye failed to recover, becoming phthisi-
`cal. In 1995 she developed a PUK of her right eye. Again, she
`received extensive topical therapy and corneal tectonic transplan-
`tation but on this occasion also received systemic immunosuppres-
`sion with two doses of intravenous cyclophosphamide totalling
`1.5 g. Her eye settled, but later she developed a dense cataract.
`Prior to cataract surgery she received intravenous cyclophos-
`phamide: four pulses prior to surgery and four pulses following
`surgery. A total dose of 6 g was given.
`Surgery was successful in both cases and there was no reoc-
`currence of PUK or complications related to immunosuppression.
`Throughout, their articular disease remained quiescent and to date
`there has been no evidence of systemic vasculitis.
`PUK is a sight-threatening condition characterized by collagen
`destruction, cellular infiltration and limbal vascular changes
`indicative of vasculitis [3, 4].
`Corneal fibroblasts are responsible for the continual turnover
`and maintenance of the extracellular matrix of the cornea, which
`is in turn maintained by the balance between tissue matrix
`
`patients (72.7%) but in 26 of these (81.3%) other disease control
`measures had been employed.
`Twenty-nine patients (28.4%) were switched following the
`advent of nausea. Twenty-one (72.4%) of these reported improved
`symptoms on the parenteral drug but only 14 (48.3%) had received
`an anti-emetic and only seven (34.5%) had been advised to try
`splitting their oral MTX dose prior to the switch. Three of the
`four patients switched after developing mucositis reported an
`improvement; only one of these had been advised to use increased
`folate supplementation and none of them had tried splitting the
`oral dose.
`Other reasons for switching included non-specific malaise
`(five patients), abdominal pain (four patients) and weight gain.
`A significant number of patients on suboptimal doses of oral
`MTX are switching to the parenteral form (and presumably other
`DMARDs or biologics) without adequate attempts at dose
`escalation. Similarly, simple symptom control measures are not
`routinely being employed to deal with common side-effects.
`Parenterally administered MTX is generally better tolerated and
`there is a suggestion that it is more efficacious but firm conclusions
`cannot be drawn due to the retrospective nature of this analysis
`and the lack of an appropriate control.
`
`Key messages
` Attempts at dose escalation and simple
`symptom control measures should be
`employed before switching from oral to
`parenteral methotrexate.
`
`Rheumatology
`
`We would like to thank our audit coordinator, Mrs Angela Wood,
`for her help with tracing the notes and analysing the data.
`
`The authors have declared no conflicts of interest.
`
`R. K. MOITRA, J. M. LEDINGHAM, R. G. HULL, F. C. MCCRAE,
`A. L. THOMAS, R. SHABAN, K. R. MACKAY
`
`Rheumatology Department, Portsmouth Hospitals NHS Trust,
`Portsmouth, Hampshire, UK
`Accepted 8 October 2004
`Correspondence to: R.K. Moitra, Department of Rheumatology,
`North Hampshire Hospital, Aldermaston Road, Basingstoke
`RG24 9NA, UK. E-mail: rkmoitra@doctors.org.uk
`
`1. Godfrey C, Sweeney K, Miller K, Hamilton R, Kremer J. The
`population pharmacokinetics of long-term methotrexate in rheuma-
`toid arthritis. Br J Clin Pharmacol 1998;46:369–76.
`2. Hamilton RA, Kremer JM. Why intramuscular methotrexate may
`be more efficacious than oral dosing in patients with rheumatoid
`arthritis. Br J Rheumatol 1997;36:86–90.
`3. Bingham SJ, Buch MH, Lindsay S, Pollard A, White J, Emery P.
`Parenteral methotrexate should be given before biological therapy.
`Rheumatology 2003;42:1009–10.
`4. Brooks PJ, Spruill WJ, Parish RC, Birchmore DA. Pharmacokinetics
`of methotrexate administered by intramuscular and subcutaneous
`injections in patients with rheumatoid arthritis. Arthritis Rheum
`1990;33:91–4.
`5. Mehta DK, ed. British National Formulary, Vol. 47. London:
`British Medical Association and Royal Pharmacological Society of
`Great Britain, 2004.
`
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