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Women With RA, Other Diseases, May Have Trouble Accessing Methotrexate Because of Abortion Restrictions

Everyday Health logo Everyday Health 7/1/2022
Women with inflammatory diseases such as rheumatoid arthritis (RA) have taken to social media to post about their problems accessing the medication methotrexate since Roe v. Wade was overturned by the Supreme Court. Although the drug has been used for decades to successfully manage RA, lupus, and psoriatic arthritis (PsA), filling or even getting a prescription for methotrexate in some parts of the country is getting more difficult for women of childbearing age. Are Methotrexate Pills the Same as Abortion Pills? No, but methotrexate is also prescribed to treat ectopic pregnancy, which is when a pregnancy starts outside the uterus (typically in the fallopian tubes) and is not considered viable. In these cases, which are considered life-threatening to the person affected, methotrexate can often be used to end the pregnancy without surgery. It works by interfering with the folic acid in the body, which stops the cells from dividing. Because the drug can cause a pregnancy to terminate, some pharmacists in states that have added further restrictions that limit or ban abortions may hesitate to fill methotrexate prescriptions for women of childbearing age because of legal concerns. ACR Is ‘Following This Issue Closely’ The American College of Rheumatology (ACR) issued a statement on social media on June 30, 2022, about methotrexate access. “ACR is aware of the emerging concerns surrounding access to needed treatments such as methotrexate after the recent decision in Dobbs v. Jackson Women's Health Organization . We are following this issue closely to determine if rheumatology providers and patients are experiencing any widespread difficulty accessing methotrexate, or if any initial disruptions are potentially temporary and due to the independent actions of pharmacists trying to figure out what is and isn't allowed where they practice. "The ACR has assembled a task force of medical and policy experts to determine the best course of action for ensuring our patients keep access to treatments they need." Abortion Regulations Cited as Reason to Deny Methotrexate to Women of Childbearing Age In states like Texas, where abortion providers or “abettors” to a termination can be fined up to $10,000 or charged with a felony, some pharmacists are declining to fill prescriptions for methotrexate, according to a Slate story published on May 24, 2022. A June 24 tweet from a methotrexate user whose profile lists Michigan as his location: “Just got off a video visit with [child’s] rheumatologist. Because of today’s ruling, his department is taking all their female patients off any meds with teratogenic risks, because such medicines might result in the miscarriage of any unplanned pregnancies they might incur.” The Drug Is a Fundamental Part of Arthritis Treatment These reports are very dismaying and alarming, says Jonathan Greer, MD , a rheumatologist at Arthritis & Rheumatology Associates of Palm Beach in Florida and a medical adviser to the arthritis advocacy organization CreakyJoints . “Methotrexate is one of the mainstays of disease management for conditions such as rheumatoid arthritis, lupus, and psoriatic arthritis; it’s a first line drug in RA patients, which affects about 1 percent of the population in this country,” he says. RELATED: Methotrexate for Rheumatoid Arthritis Treatment: An Oldie but Goodie “To deny women of childbearing age methotrexate for fear that they may use it for reproductive health issues is not appropriate; it should be left up to the healthcare provider to write the prescription as needed,” Dr. Greer says. What Is Methotrexate? Methotrexate is one of the most effective and widely used medications for treating types of inflammatory arthritis, according to the Arthritis Foundation . In addition, the affordable drug is considered safe and is used to treat many diseases, including Crohn's , severe psoriasis, severe atopic dermatitis , and some cancers. Denying People With RA Methotrexate Is Unethical Cheryl Crow, an occupational therapist, patient advocate, and the founder of Arthritis Life , a patient education organization whose mission is to educate, empower, and support people living with inflammatory arthritis, has taken methotrexate as part of her RA treatment for 16 of the last 19 years. “I was diagnosed with severe rheumatoid arthritis at 20 years old and I experienced a complete medicated remission for the first seven years, due specifically to the combination of methotrexate and my biologic,” says Crow. She credits these medications with her ability to live a relatively normal life, including a healthy pregnancy. “Taking these away from patients is unethical, in my opinion,” she says. Access to Methotrexate May Depend on Your Home State The issue seems to be contingent on the state where a patient lives, says Crow. Because Crow lives in Washington state, where abortion is legal, she hasn’t had any problems getting her RA medication. “Patients are having difficulty in states that have more strict anti-abortion laws, like Texas and Michigan,” she says. So far Crow has seen or been contacted by people from at least four different states who have had trouble getting their methotrexate. “ Three categories of barriers I've seen are (1) The pharmacist will not physically give the patient the prescribed medication as prescribed by their rheumatologist. (2) The pharmacist is delaying giving the patient methotrexate while they sort through the potential legal issues around giving it to them, which included in one case making sure they had documentation the patient was on birth control, and (3) a rheumatologist saying across the board their entire clinic is currently not prescribing methotrexate due to potential legal issues,” she says. Is the Panic and Outrage on Social Media Warranted? As the ACR statement suggests, it is hard to determine the breadth of the problem. At press time, EH was unable to locate official reports or specific data about methotrexate denials. Time will reveal more. Nevertheless, the fear is real. More Medical Mistrust: Laws Threaten Doctor-Patient Relationships These restrictions pose a real threat to the doctor-patient relationship, says Crow. “My doctor has known me for two decades, she has cared for me through a pregnancy, grad school, wedding, cross-country moves, traveling around the world, postpartum depression, a car accident, and even more. When she writes me a prescription, it's because I need it, ” says Crow. No one should interfere with a doctor’s recommendations to their patient, she adds. Who Decides Appropriate Treatment? “It should be up to the doctor to prescribe this medication for the appropriate conditions, and no one should be dictating to us what we should do for our patients who need this for rheumatologic diseases,” says Greer. Will Abortion Bans Discourage Doctors From Prescribing Methotrexate? “While it’s true that methotrexate is used in certain issues in pregnancy termination, in rheumatology, we warn our patients in advance that this drug can cause fetal malformation and cause damage to the developing fetus. That’s why we make sure that our patients of childbearing age who are on this drug practice contraception, especially if they are sexually active,” he says. Greer says he had an RA patient get pregnant while on methotrexate, and she had to terminate the pregnancy because of the potential fetal damage. Will rheumatologists be more reluctant to prescribe methotrexate to women of childbearing age now because (at least in some states) they would no longer have the option to get an abortion in that scenario? “It’s definitely a concern among all rheumatologists. We have to have these discussions early on about the risks that the drug carries if a pregnancy occurs, and then continue those discussions throughout our treatment with methotrexate,” he says. Greer continues, “I can’t speak for all rheumatologists, but there are fears among some who may restrict their prescribing habits in the future. It won’t change how I prescribe methotrexate; I’m going to do what’s right for my patients — my patients come first.” What to Do if You’re Denied Methotrexate (at Your Pharmacy) One way to address any pushback that may come at the pharmacy around filling methotrexate is for doctors to write on the prescription that it is for a specific disease, for example, rheumatoid arthritis or psoriatic arthritis, Greer suggests. “That might allow the pharmacist to feel better about filling the prescription,” he says. Crow suggests seeking guidance from your rheumatologist or seeing if a different pharmacy or pharmacist will fill your prescription if you get turned down for a refill on your medication. Several organizations are collecting patient stories in order to better advocate for people who experience problems getting methotrexate as prescribed. If you have been denied or had difficulty accessing methotrexate since Roe v. Wade was overturned, here are the groups to contact: American College of Rheumatology (ACR) In its statement, the ACR asks the community to report specifics. “We are asking patients who have experienced challenges accessing methotrexate to email advocacy@rheumatology.org with details.” Arthritis Foundation Send a message to advocacy@arthritis.org or @AFAdvocacy . Crohn's & Colitis Foundation The Crohn's & Colitis Foundation is calling for IBD patients to contact advocacy@crohnscolitisfoundation.org . Global Healthy Living Foundation and CreakyJoints The Global Healthy Living Foundation and CreakyJoints , advocacy organizations, are encouraging people to contact their elected officials to let them know the importance of this vital medication. To share your story with CreakyJoints, send a tweet to ‪@zoerothblatt .
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