Methotrexate Patients and Post-Dobbs Fear

Apologies for the conversational detour here—new film or TV content is coming later this week. There is something I need to rant about, and this is as good a place as any to do it.

For the second time in two years, Republican lunacy is scaring autoimmune disease patients. You might recall the great hydroxychloroquine stupidity of 2020, a craze eventually replaced by mass consumption of ivermectin. What we have now is a little different: Confusion over the continued availability of methotrexate.

In the case of Plaquenil, some patients really did face shortages. I was fortunate: my supply never ran out, even as idiots like my uncle (physically healthy, mentally not so much) attempted to order a side of hydroxychloroquine with their MyPillows. My methotrexate refill isn’t due for another month, and hopefully there are no disruptions. I’ll provide an update once my prescription’s in hand.

It will be weeks before my next rheumatology appointment, and who knows what anecdata the office will have to share by then. My first opportunity to speak with a prescriber came today, at a routine GI appointment. To the best of my doctor’s knowledge, none of his patients have yet encountered difficulties obtaining methotrexate. He has seen some of the same “the end is nigh” tweets as me, and we both felt there was something incomplete about at least a couple of those stories.

“Don’t worry” doesn’t carry much weight these days

He was adamant that his patients will not be denied the inflammatory bowel disease treatments they need. Even though he’s not my methotrexate prescriber — my rheumatologist is — I’m glad to have an advocate like him in my corner. (He’s no Albert Beck, that’s for sure.) I’m also angry to think anyone might have to fight this battle on my or any other patient’s behalf. And it’s anger as much as fear and anxiety that’s driving a lot of the conversation I’ve seen so far online.

The more some patients are told not to worry, the more they probably will. After being not to worry about things like Trump or Roe, all “don’t worry” tells them is that it’s time to panic. Adding to their confusion, some of the more fearmongering posts about methotrexate contain medical inaccuracies. Terms like “teratogenic” and “abortifacient” are sometimes used incorrectly or interchangeably. Authors might speak broadly about methotrexate as an abortifacient without understanding how it is used in treatment of ectopic pregnancy. Further muddying the waters, it’s unlikely that most Republican lawmakers are any more knowledgable about any of this themselves.

While I’m confident that in the long run I’ll have access to the medication I need, I understand where others are coming from and share their concerns. The number of hoops I jump through each year to manage conditions I’ve had since childhood is already insulting. Losing access to methotrexate based on other people’s politics or ignorance, even briefly, right after losing one’s right to bodily autonomy, would cruelly heap one indignity upon another. Dragging theoretical pregnancies into it makes things even thornier. Every patient’s reproductive story is different, but mine goes roughly like this:

• My fertility is questionable due to a history of extensive abdominal surgery.
• My OB-GYN has advised against attempting pregnancy due to my surgical history and general distrust of my immune system.
• The crown jewel of this pointless exercise: I’m a married, monogamous lesbian.

The bottom line is this

For some patients, hopefully few, trouble is on the horizon. Pending clarification of new legislation, some prescribers (or their bosses) will be afraid to prescribe methotrexate, at least temporarily. According to Stat, fear is already rampant in Texas. Some pharmacists may likewise be afraid to fill prescriptions. The more aggressively anti-choice their state is, the most fearful they will be.

But physicians who practice evidence-based medicine will not, in great numbers, abandon use of methotrexate, a drug that works well for many patients. Even strongly anti-choice states are likely to understand its utility. Governor John Bel Edwards signed two strict anti-abortion bills into Louisiana law last month. In SB388, you’ll find this:

It defines an “abortion-inducing drug” as “any drug or chemical, or any combination of drugs or chemicals, or any other substance when used with the intent to cause an abortion,” including methotrexate. Methotrexate used to treat conditions like rheumatoid arthritis or lupus is not used with the intent to cause an abortion. It continues: “abortion-inducing drug shall not mean a contraceptive, an emergency contraceptive, or the use of methotrexate to treat an ectopic pregnancy.”

I’m not a physician, but I’m a very long-time patient. My best guess is that when the dust settles, doctors will have to jump through more hoops (like prior authorizations) in order for us to procure our medications. And they’ll do it, because they care a lot more about their patients than right-wing politicians care about their constituents.

May, 2023 Update: This month, for the first time since writing this article, I encountered difficulty getting my methotrexate prescription filled. Due to absorption problems caused by Crohn’s disease, I use injectable methotrexate and there’s currently a nationwide shortage of it. Pills are still available, so I’ll temporarily revert to that method. Is the shortage at least partially attributable to increased demand following the Dobbs decision? I don’t know.