CONTEXT: Peer reviewed literature review of methotrexate auto-injectors predominantly in RA | Interesting that despite the huge datasets involved in this research, it can come down to whether or not the patient can hold the auto-injector well enough because of their arthritis, to self administer the MTX…When science meets common sense.
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1. “This narrative review is based on the following premises: 1) patient’s perceptions about medication play an important role in adherence and, in consequence, in clinical outcomes and medical costs of chronic diseases such as RA; 2) the SC MTX has gained attention among rheumatologists during the last years, and devices for self-injection have increased as an alternative to classic syringes; 3) these new marketed devices have shown a high level of usability, acceptance, and satisfaction that may lead to enhance the clinical outcomes.”
2. “The literature search strategy was focused on the following question using the PICO framework:23. “How does the use of pens/autoinjectors versus others forms of injection affect medication adherence and perceptions of patients with RA receiving long-term therapies?”
3. “In short, the concept and measure of adherence are as complex and variable as factors affecting it which range from patient expectations and attitudes, and disease characteristics, to convenience, cost, route of administration, adverse events, and practitioner support.25 If focused on RA several studies have also shown different estimates of MTX adherence because of the heterogeneity in the assessment methods.12 For instance, MPR, the Compliance Questionnaire Rheumatology (CQR), the Visual Analogue Scale (VAS), the Medication Event Monitoring System (MEMS), drug record registry, claims data, and the Medication Adherence Report Scale (MARS-5)12,13,15 have been used throwing a variety of results that do not allow to build a clear pattern of factors that influence adherence and persistence.”
4. “The use of parenteral MTX is recommended to be also considered in patients with highly active disease, poor adherence to oral treatment, taking multiple drugs, or obesity.16. Additionally, considering the expert consensus document by Tornero-Molina et al, in RA patient’s refractory or intolerant to oral MTX and even poor-adherents, the switch to SC MTX is recommended before introducing a biologic agent.17 The assessment of effectiveness and safety of SC MTX has been mainly focused on RA and evidence highlights the superior clinical efficacy of SC MTX over oral MTX.26 Moreover, the higher drug exposure resulting from SC administration does not entail a higher risk of gastrointestinal adverse events or increased safety issues.”
5. “A multicenter, randomized, double-blind trial comparing the efficacy and safety of oral and SC MTX in patients with active RA found that SC administration was significantly more effective than oral administration with no differences in tolerability.20 This fact has also been described in a prospective study even without an increase in adverse effects.28 Another study in a prospective cohort of patients with early RA concluded that initial SC MTX was associated with lower rates of treatment failures and greater clinical efficacy than oral MTX, with no difference in toxicity taking into account the expected difference in MTX bioavailability when SC MTX is administered compared to oral MTX at higher doses.26 A short-term study demonstrated that oral split doses of MTX are better than an oral single dose and similar to parenteral MTX in terms of efficacy.29 However, MTX given orally shows a lower absorption and a worse safety profile regarding gastrointestinal toxicity that may justify the switch to SC MTX instead to as we have previously mentioned, based on the expert consensus document by Tornero-Molina et al., and should being re-evaluated periodically, in situations where initial doses are necessary as in overweight patients, the switch from oral MTX to SC MTX is also recommended.17 In support of this, evidence has demonstrated that SC MTX both as initial therapy in naive patients20,26 or subsequent therapy in non-responder patients improves treatment persistence, and clinical efficacy mainly due to its favorable bioavailability,30 and optimizes the use of healthcare resources.27 Notably, a recent subanalysis of the RA Excellence project in Spain showed that MTX escalation to full doses is not done with adequate”