Methotrexate

The second arm of therapy is our DMARDs, disease-modifying anti-rheumatic drugs, which slow disease progression.

Methotrexate is the first line DMARD, mechanism of action, inhibition dihydrofolate reductase.

Okay, so there are instances in which we might not use methotrexate.

Let's say a patient happens to have pre-existing pulmonary fibrosis, okay, because methotrexate can cause pulmonary fibrosis.

Rheumatoid lung, which we see with advanced rheumatoid arthritis, can lead to pulmonary fibrosis in patients.

But methotrexate is our first-line DMARD.

You have to know it's a dihydrofolate reductase inhibitor.

Trimethoprim, an antibiotic, and puromethamine.

None of the drugs work on me.

Methotrexate didn't work.

None of the standard DMARDs, you know, that we had in the 80s and 90s, penicillamine and self salazine and gold injections and all of those things, none of those worked.

So I was really existing on steroids, which of course is not good.

Yeah.

They started off with the traditional Trexall tablets, and those weren't cutting it, and meanwhile, my joints are continuing to deform, truly, um, in constant pain, to the point where I could barely make it down the stairs-

Yeah

...

And that's when it was official that, yeah, you've got it.

And then all the plan coming out then, R-Trop, Keno, Pytos, Methotrexate, radiation, all that stuff was just like, fuck, here we go.

And it was just, it was just, um, that first time around, I guess it was strange because obviously I'd never been through it before.

None of us had been through this sort of thing before.

they're bacteria.

Methotrexate will do a carpet bombing of bacteria.

It'll kill all your good guys.

Should replace those.

So you move to systemic immunomodulatory therapy, or IMT.

Methotrexate is usually the first line here, right?

Yes.

And as an ophthalmologist, you do not do this alone in a vacuum.