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Too Late for Methotrexate

Too Late for Methotrexate

  • Photo courtesy of Irina Litvin, D.O.
    Photo courtesy of Irina Litvin, D.O.
  • Photo courtesy of Irina Litvin, D.O.
    Photo courtesy of Irina Litvin, D.O.
  • Photo courtesy of Irina Litvin, D.O.
    Photo courtesy of Irina Litvin, D.O.

Oftentimes, we take for granted the advances made in medicine. All it takes to open our eyes is just one patient who missed the treatment boat. So many diseases have been eradicated thanks to the work of dedicated physician scientists. The treatment of rheumatoid arthritis has been marked with extraordinary progress allowing many patients to live out a natural life expectancy.  

The hands pictured here belong to a 75-year-old woman who has allowed me to share this image in the hope of motivating young physicians. She is forever grateful to those who help her function daily and, she doesn’t harbor a bit of resentment that she was born too early to benefit from biologics, methotrexate and other drugs that have revolutionized rheumatology.

Her story began with joint pain and stiffness which eventually led to a rheumatoid arthritis diagnosis. She was 45 years old and was treated with prednisone and NSAIDs. Over time, her physical condition deteriorated as her dorsal interosseous muscles atrophied, ligaments became lax and joints eroded.  Unfortunately, this was a time in which treatment was limited and patience was advised.  By the time she was started on methotrexate — today’s gold standard — she could not turn house keys or button her blouse. Her rheumatoid arthritis had rendered her hands useless.

As physicians training in the 21st century, we don’t always feel a sense of calamity for patients with RA. There are a myriad of options for treatment, and more often than not, patients will respond to treatment and improve. It is imperative that as we continue our training, we remember to stay humble and grateful to all of the advances made. Even more so, we must continue to blaze the path for new discoveries as we provide the best care possible.


Irina Litvin, D.O., is a physician and rheumatology fellow at SUNY Downstate in Brooklyn, N.Y.



Gyorgy Nagy and Ronald F van Vollenhoven. "Sustained biologic-free and drug-free remission in rheumatoid arthritis, where are we now?" Arthritis Research and Therapy. Aug. 3, 2015. DOI: 10.1186/s13075-015-0707-1


What happens when the methotrexate allows the person to develop open wounds on the skin? The person gets some skin breakdown due to perspiration. The methotrexate has interfered with the immune system leading to Stage 1 wounds. What is the patient's option?

Randi @


Thank you for your interest. Are any confounders at play? Underlying conditions? As you can tell, there are a myriad of other questions that stem from the clinical situation you've described. It's very difficult to ascertain without an history and physical examination. These items are essential always, and certainly when dealing with immuno-modulating medications. It would be best to consult with your local rheumatologist for alternative options.

Dr. Litvin

Irin @

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