Will my new arthritis pill cause side-effects?

Every week Dr Martin Scurr, a top GP, answers your questions

I’VE been diagnosed with psoriatic arthritis, and for the last three years have managed it by taking antiinflammatory tablets on and off. The arthritis has now affected several joints and is making my work uncomfortable.

I have been advised to start methotrexate but have resisted because of the possible side-effects. Am I being too cautious?

Paul Morris, Ely, Cambridgeshire.

YOU have a form of arthritis which develops in around 15-30 per cent of patients with psoriasis (a chronic skin condition that causes patches of red, flaky, often scaly skin).

Psoriatic arthritis causes severe pain and inflammation around the affected joints — typically the hands, feet, knees, spine and elbows. As with psoriasis itself, psoriatic arthritis is thought to occur as a result of the immune system mistakenly attacking healthy body tissues, although it’s not clear why some psoriasis patients develop it while others do not.

The first avenue of treatment is usually administering an antiinflammatory drug, such as diclofenac or naproxen, to control the inflammation and relieve the pain. You need a high enough dose for it to work properly, and it takes several weeks to take full effect, as your GP or rheumatology specialist will have advised.

(It is worth noting that around 40per cent of patients with this form of arthritis are obese and research shows that losing at least 10 per cent of their weight can quickly improve their response to treatment; losing weight will also reduce their risk of diabetes and heart disease, which is raised, although it’s not clear why).

If the arthritis does not respond well to anti-inflammatories, the next option is methotrexate.

This is known as a disease-modifying drug — it works to dampen down the underlying disease process rather than simply treating its symptoms, and in this case acts by suppressing the over-active immune system.

It is an effective drug, although this has been difficult to prove in clinical trials.

The drug is usually given as a tablet once a week, but if higher doses than 17.5mg are needed, you’re likely to be given a weekly injection instead (higher doses are not as well absorbed when taken orally).

As you know, the drug carries a risk of side-effects, including liver damage or bone marrow problems. Because of this, patients are usually given monthly blood tests to check their liver and bone marrow function: you will also need to take supplements of folic acid, as this will offer some additional protection against any side-effects.

Patients must also avoid alcohol completely, as the combination of methotrexate with alcohol is potentially more dangerous for the liver than either alone.

If you follow these precautions, methotrexate is a good option. The benefits of taking it almost certainly outweigh the side-effects — and if the drug affects you adversely it will be stopped and other, even more advanced, treatments will be considered.

These include ‘biologic’ agents called TNF inhibitors (specifically etanercept, adalimumab, infliximab, or golimumab), which target a protein believed to be involved in the inflammation.

however, the high cost of these drugs means that they are of limited availability, and there are strict criteria for their use, which must be under the expert care of a rheumatologist. MY GRANDDAUGHTER, aged four, has been diagnosed with selective mutism. How can this be treated and can it be cured? I hope you can give me some answers.

Alice Corner, Stirling. SELECTIVE mutism is an anxiety disorder where a child refuses to talk, or is reluctant to in certain situations, such as in front of other children, despite being able to talk freely at home or around their family members.

children with this condition often have social anxiety (excessive shyness), too. They may also have trouble making eye contact, a tendency to worry, an insistence on fixed routines, and sensitivity to noisy groups of people or large crowds.

The condition is one of seven types of anxiety disorder identified in children — others include agoraphobia, panic disorder and separation anxiety disorder.

exactly why they develop is down to a number of factors, psychological, environmental and genetic (there is evidence that children whose parents have an anxiety disorder are at risk of developing one themselves).

Of course, worries and fears are a normal, natural part of childhood development, but it is classed as a disorder when the anxiety becomes persistent and starts to severely affect daily life. Although these disorders are very common — affecting one in ten children — selective mutism is itself fairly unusual, and is seen in just 0.7 per cent of children.

It typically develops before the age of five, and treatment at an early stage, under the care of a paediatrician or child psychiatrist, is essential.

Typically, the child will have regular sessions with a paediatric clinical psychologist who is trained to use a number of treatment options.

One is ‘stimulus fading’. This is where the child will be encouraged to take part in a game with another person with whom they normally speak freely, such as their mother.

Gradually, a new person is introduced into the activity. Once they are included in the conversation, the mother can withdraw — and further people can then be introduced in the same way.

Another treatment is ‘mystery motivation’, a subtle form of bribery. It involves placing an envelope, containing a prize, in a visible place, clearly labelled with the child’s name and a big question mark next to it. The child will then be told they can have the prize if they ask for it loudly enough.

MOST of these treatments are forms of behavioural training, but there have been some very small studies into treating the problem with antidepressants. however, they have not shown these drugs to be sufficiently effective in children of your granddaughter’s age.

My advice is that selective mutism can and will be cured, but patients should be referred to specialist care by the family GP.

It is not good enough to hope that the problem will disappear of its own accord. If left untreated the condition may get worse and persist into adulthood and then contribute to the development of other forms of anxiety disorder.