SPECIALTY
Rheumatology
CHIEF COMPLAINT
Rheumatoid Arthritis
COMMENTS TO SPECIALIST
This is a 41-year-old female patient with known history of rheumatoid arthritis (RA) was seeing a rheumatologist until she lost her insurance in 2019. Patient would like to restart methotrexate. Prior RA notes indicate patient decided to discontinue using the prescription due to nausea. Patient denies that she discontinued, and states rheumatologist told her the prescription was not effective enough. I am comfortable restarting methotrexate. However, this patient has mild, elevated liver function test (LFT) and known diagnosis of fatty liver. Weight loss advised. Enbrel is available with patient assistance, but she wants trial of methotrexate due to convenience and price. Patient refuses in-person rheumatology consult due to cost. I am unable to obtain more than 2 years of rheumatology history – prior history destroyed. Initial labs as well as more recent labs are attached. Other attachments include LFT, chest X-ray, eye exam, etc.
MAIN QUESTION
Would you advise methotrexate trial, given abnormal LFT vs other disease-modifying antirheumatic drug (DMARD). If methotrexate is restarted, how often should the patient receive an LFT? At what threshold should abnormal LFT occur before I stopping methotrexate? If alternative DMARD is advised, please outline recommended monitoring schedule? The patient’s last CXR and purified protein derivative (PPD) was 11/2020.
For reference only. This eConsult is based on an actual request for specialist consultation. The primary care provider, specialist, and patient are de-identified to protect private health information (PHI).
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