W. Benjamin Nowell, PhD, on Patient Perceptions of MTX Use in RA, PsA

Methotrexate (MTX), although a frequently used therapy for rheumatoid arthritis (RA) and psoriatic arthritis (PsA), is associated with potential adverse effects and tolerability issues. Additionally, there is a shortage of patient-centered studies that focus on patients’ experience with MTX and how their experience relates to adherence and outcomes.

In a new study, W. Benjamin Nowell, PhD, from the Global Healthy Living Foundation, and colleagues examined beliefs and perceptions of more than 371 patients with RA or PsA who were currently receiving or had received treatment with methotrexate therapy.

Findings of the study indicated that most patients experienced side effects that they attributed to MTX use; most patients also acknowledged the importance of receiving treatment with MTX; and most patients believed that MTX use prevented their condition from worsening.

Rheumatology Consultant spoke with Dr Nowell, who is the director of patient-centered research at CreakyJoints, the nonprofit digital patient community of the Global Healthy Living Foundation in Upper Nyack, New York, about the research presented at the 2019 American College of Rheumatology (ACR)/Association of Rheumatology Professionals (ARP) Annual Meeting.

Rheumatology Consultant: You and your colleagues evaluated data on patient beliefs and perceptions about MTX therapy. Why is it important for a clinician to understand their patients’ viewpoint of their treatment?

W. Benjamin Nowell: It is important because MTX is a common first-line therapy for RA and PsA. The patient’s experience with first‑line therapy is very important, because although a doctor can prescribe a medication, ultimately it is the patient who is going to get the prescription filled or not and take the medication or not. If patients are feeling lousy while taking a medication, and they attribute that feeling to the medication itself, then you risk having patients not take what you prescribe. In the bigger scheme of things, it should matter because if a patient is not adhering to their medication, then it seriously inhibits providers’ efforts to get the patient’s disease activity under control. Doctors are pretty aware of the fact that patients find MTX intolerable at times. For our study, we were trying to give voice to that patient experience of common side effects encountered while with MTX, and which were most bothersome.

RHEUM CON: Why might a patient want to discontinue treatment with MTX without letting their doctor know?

WBN: That is a good question. Patients may experience many bothersome side effects while receiving treatment with MTX and think it’s not worth the trouble. Therefore, they need support to help them stay adherent and be able to communicate with their doctor right away so that the doctor can offer suggestions about how to make MTX more tolerable and consider other options for treatment optimization. There are many reasons patients might not adhere to a particular treatment, but what’s important is that we know that patients are experiencing things that are really uncomfortable about MTX. From the study results, we found that fatigue is common, as well as gastrointestinal (GI) issues. Experiencing those side effects are not fun for anyone. It is important to determine how we can help patients either stay on MTX or find something that works better for them. It is also important to help prepare patients to take the medication, so they know what to expect. Yes, printouts and patient education are very important, but I think part of any education is the timing of it and helping patients have realistic expectations. One of those expectations, I think, is to make sure that patients know to let their doctor know when they are struggling or uncomfortable on a medication.

RHEUM CON: What were the most important findings of your study?

WBN: The most important finding was that of the side effects. Fatigue was the most common one cited by people who were currently receiving treatment with MTX and people who had discontinued MTX treatment—that was 44% of the whole cohort. What was interesting from the findings was that among those patients who had discontinued MTX, they were more likely to report having experienced GI issues as side effects than the patients who were currently receiving MTX treatment. Specifically, a significantly higher percentage of people who had stopped taking MTX reported that they had abdominal pain and nausea while they were on MTX compared with people who were still on it. We might infer from that that a GI issue is what is more likely to make a patient say, “I am not going to take this medication.”

RHEUM CON: What is important for rheumatologists to know about the study?

WBN: The key takeaway is that we need future research to learn how we can best optimize treatment adherence and how we can best enhance treatment optimization. We need new strategies to support MTX adherence and also strategies to support treatment optimization so if a medication cannot be tolerated by a patient, we can get them on treatment that is more suitable for them as soon as possible.


Nowell WB, Karis E, Gavigan K, et al. Patient beliefs and perceptions of methotrexate for the treatment of rheumatoid arthritis and psoriatic arthritis [abstract 2256]. Arthritis Rheumatol. 2019;71(suppl 10). Presented at: 2019 ACR/ARP Annual Meeting; November 8-13, 2019; Atlanta, GA. Accessed February 6, 2020.