Methotrexate or Celebrex to treat AAU?

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Vaclav
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Joined: Sun Aug 25, 2013 12:34 pm

Methotrexate or Celebrex to treat AAU?

Post by Vaclav » Tue Aug 27, 2013 2:22 pm

Hi,

I am 40 years old man and had my first flare up of anterior uveitis 7 months ago. It happened two days after I was vaccinated for my pollen allergy so I suspect it might be related. Unfortunately since my first flare I am unable to get completely rid of eye inflammation. I am responding quite well to steroid drops although also several steroid injections next to my eye were required to control my uveitis but after tapering drops to zero I have it back in couple of days. I was diagnosed HLA B27 positive but no autoimmune disease confirmed - suspected for AS due to my back pain from time to time but X-ray and MRI results were negative although my back pain lasts for years. Anyway I remain in contact with my rheumatologist who investigated me and asked for help with my uveitis because I did not want to rely on topical corticosteroids forever (the only treatment at Ophtalmology). She suggested to start with Salazopyrin due to realtively low toxicity (sulfasalazine) and it seems it helps as my uveitis is milder and better controlled but it did not help me to achieve remission. Therefore I am now on Celebrex as well and consider to try methotrexate because I had increased heart rate around 100/min with Celebrex but it is off and after two weeks on Celebrex I do not experience heart rate problems anymore and have about 80/min. During that time I gave up some herbs supplement so I suspect that interacting might be an issue. I wonder if I should stay on Celebrex or to give MTX a chance. According to your experience what has better results in long term? I am aware of side affects of both meds but my doctor does not seem to be in favour of using Celebrex in 400mg/day dosage for such a long time as two or more years and would rather support MTX if my blood tests will be fine and my body will be able to accept it.

Thank you very much for this forum and support you provide as I found here a lot of useful information as well as on Uveitis.org

Vaclav

Mike Bartolatz
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Joined: Fri Feb 06, 2004 9:58 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Mike Bartolatz » Tue Aug 27, 2013 6:09 pm

Vaclav,
the doctors will have to guide as to what is appropriate for YOU depending on your health and the reaction to various meds.

that Said, Methotrexate might well be the better of the two drugs in my lay opinion if you can tolerate it but it takes about six months for it to start working so be patient. you might have to stay on steroids and then slowly taper at the six month point for example to keep your eyes quiet, off all steroids and without inflammation for TWO years on either the Celebrex or the Methotrexate. often the amount of MTX has to be slowly increased until as much as 25 once a week is given. at 25 they will switch to injectable MTX with fewer side effects and about half the drug required to treat you.

Sulfasalzine doesn't work well for uveitis. the DMARD drugs are Methotrexate, Cellcept, Imuran
then TNF A drugs Remicade or Humira
close section gallium scan of the Sacrum might be required to image initial stages of Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, Crohn's disease and Ulcerative colitis all linked to the HLA B27 gene and Uveitis.

Take care,
Mike Bartolatz
Mike Bartolatz
Moderator

Vaclav
Posts: 5
Joined: Sun Aug 25, 2013 12:34 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Vaclav » Wed Aug 28, 2013 3:46 pm

Mike,

thanks for your opinion and quick reply. I am currently off the steroids for about one week and I was able to manage it for the time being with the help of Celebrex waiting for liver tests before starting with MTX. TNF A drugs are not available for all patients in my country (Czech Republic) due to its costs so I hope that MTX will help me and I will have no serious side effects. I have been treated by ophtalmologist only for couple of months with topical steroids but due to frequent reccurence I now rather rely on help of my rheumatologist to achieve long term remission and she is really willing to help although I have no other signs of systemic desease which was not the case with another rheumatologist I visited sending me back to Ophtalmology. There are no available ocullar immunologists in the area where I live so I am happy to have an alternative in rheumatology.

Have a good day,

Vaclav

Mike Bartolatz
Posts: 6595
Joined: Fri Feb 06, 2004 9:58 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Mike Bartolatz » Thu Aug 29, 2013 10:02 pm

Czech Republic

Martin Filipec, MD
Eye Clinic Lexum
U Spolecenske zahrady 3
140 00 Prague 4
Tel: 420-244-016-441-443 or 420-777-2030-44.
Email: mfilipec@hotmail.com


This Ocular immunologist trained in the USA under DR Foster at Harvard Medical school. He can work with your rheumatologist and knows what to do for this stuff.

MTX takes about six months to start working so be patient as the dose is slowly increased, make sure you take folic acid supplement about 11 hours after taking your MTX dose. it will help to keep things like hair loss to a minimum. if you have upset stomach, ask for a proton pump inhibitor medication. both MTX and Folic acid can cause stomach indigestion.

ask if you can stay on the Celebrex too as it works in about 70% of autoimmune uveitis patients. it too takes about 2 years off all steroids without inflammation before taper is begun.

Take care Vaclav,
Mike

PS: my ancestors are from Croatia
Mike Bartolatz
Moderator

Vaclav
Posts: 5
Joined: Sun Aug 25, 2013 12:34 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Vaclav » Sun Sep 01, 2013 3:11 pm

Mike,

thank you for valuable information. My doctor finally agreed with staying on Celebrex however I have some troubles with fast heartbeat. It should not be common side effect of Celebrex so I do not know if it is related to it or not but I did not experience it in the past. I hope I will be able to continue with this medication. Blood pressure seems to be no problem and I have never had any cardio problems. I am going to consult it and perhaps undergo some cardio check as I don´t want to underestimate it.

I have already found contact to Czech ocullar imunologist on Uveitis.org and tried to call. I reached a receptionist and she said they did not focus on uveitis treatment in Eye Clinic Lexum anymore. I did not have a chance to talk to Dr. Filipec in person. I will make one more attempt and send e-mail directly to him and will see if there is a possibility to meet

Take care,

Vaclav

Mike Bartolatz
Posts: 6595
Joined: Fri Feb 06, 2004 9:58 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Mike Bartolatz » Mon Sep 02, 2013 12:07 pm

Although his practice doesn't necessarily focus on treating just uveitis patients, he does have the best training possible by Dr Foster here at Harvard medical School. He should be able to use his education to help. you might want to discuss the receptionist comments too as it could send people away from him rather than get them to the best available doctor in your country. it would be interesting to learn his comments on this as he may wish to remove his name from the specialist list if that is truly the case. I can't understand why someone would go through a medical fellowship at great expense to then no longer use the specialized training.

wish you the very best,
Mike Bartolatz
Mike Bartolatz
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Vaclav
Posts: 5
Joined: Sun Aug 25, 2013 12:34 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Vaclav » Thu Jan 02, 2014 3:46 pm

Hi Mike,

I am back after some time. I can confirm that Mr. Filipec does not treat uveitis anymore. Anyway, I am now on MTX for about 3 months, last 4 weeks on maximum dosage of 25 mg/week while still been on NSAID (Celebrex replaced with Diclofenac). Unfortunately I have experienced another flare up in December. The good thing was it was resolved quite quicky and in comparison with my initial flareups it was much milder so I could taper steroid drops quite fast. It happened just in the period of replacement (couple of days after) of Celebrex by Diclofenac so I wonder if it was the reason that it takes some time until new drug starts working. What is quite disappoiting for me that MTX obviously still does not work. Do you think that it makes sense to rely on MTX if it has no treatment effect so far? I surprisingly have no side effect of taking MTX even in 25mg dosage with one small exception of 2 mouth ulcers which is good for me but I start thinking if it has any effect at all / if it is processed by my body well. I will consult it with my rheumatologist as soon as I visit her but it will not be before mid of February so your opinion wlould be useful based on your experience

I wish you all the best in 2014!

Vaclav

Mike Bartolatz
Posts: 6595
Joined: Fri Feb 06, 2004 9:58 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Mike Bartolatz » Fri Jan 03, 2014 12:22 pm

it takes a higher dose such as that which you are now taking for about 6 month period to know if MTX is going to work. you may have to switch to the injectable form of MTX at half the dose once weekly in order to get benefit and may have to add Remicade or Humira to the mix which are TNF A blocking drugs also taken for about 2 years OFF ALL Steroids without inflammation.

the Celebrex works on both COX 1 and COX 2 the voltaren only works on COX1. voltaren destroyed my stomach years ago so I had to stop it.

make sure you wait at least 11 hours before taking the folic acid when taking MTX so that the Folic acid doesn't negate the drug methotrexates mechanism of Action. if you go to injectable MTX it may work better for you too at half the dose you are now on.
many individuals have to add a TNF A blocking drug when they are HLA B27 positive especially those who have had uveitis for a long time before going on DMARD drugs.

wish you the best,
Mike
Mike Bartolatz
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Vaclav
Posts: 5
Joined: Sun Aug 25, 2013 12:34 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Vaclav » Sat Jan 04, 2014 4:17 am

Thank you for your advice.

I hope MTX will finally start working. The problem with TNF-A blocking drugs in my country is that I will not be able to get it approved by health insurance company for uveitis regardless of how much money I am paying for insurance. I am happy I could get MTX at rheumatology because anything except steroids is (unfortunately) considered as unusual by most of ophtalmologists but I learned on this site as well as on Uveitis.org that it is not sustainable way of treatment in the long perspective.

It is similar story with Celebrex. Insurance company stopped paying for it unless I already have gastric ulcers or similar problems but in my view it is already too late. I might consider to pay it from my pocket later but for the time being I accepted replacement of the drug. I have also received omeprazolum (APO-OME 20) from my doctor to prevent stomach issues and for the time being I have subjectively no troubles. I just wonder if the efficacy of both drugs is the same because since I do not use Celebrex I have flare up again and it was not the case for last 4 months while I was on Celebrex

Folic Acid I use properly as you described. If MTX does not work I will ask for injectable form

Vaclav

Mike Bartolatz
Posts: 6595
Joined: Fri Feb 06, 2004 9:58 pm

Re: Methotrexate or Celebrex to treat AAU?

Post by Mike Bartolatz » Sat Jan 04, 2014 4:19 pm

no the voltren is not as effective in most people when compared to Celebrex.
here in the USA the drugs Dolobid (difusinal) and naprosy (naproxen) seem to work better than Volatren (diclofenac). they are prescription but generic so cost less than the brand name.

the injectable MTX has better results than the oral with less stomach irritability too.

take care,
Mike
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