|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 1 | Page : 79-80
Use of coffee for alleviating methotrexate intolerance in rheumatic diseases
Anand Narayan Malaviya, Sadhana Singh Baghel, Shallu Verma, Ravita Thakran, Christy Messi
Department of Rheumatology, Joint Disease Clinic, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India
|Date of Web Publication||14-Mar-2019|
Prof. Anand Narayan Malaviya
Department of Rheumatology, Joint Disease Clinic, Indian Spinal Injuries Centre, Sector-C, Vasant Kunj, New Delhi - 110 070
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Malaviya AN, Baghel SS, Verma S, Thakran R, Messi C. Use of coffee for alleviating methotrexate intolerance in rheumatic diseases. Indian J Rheumatol 2019;14:79-80
Nonadherence to methotrexate (MTX) treatment in patients with rheumatoid arthritis (RA) (~1/3rd patients) has been a major challenge in daily practice. This may also be true with the use of MTX in other systemic immunoinflammatory rheumatic diseases. A major component of MTX-nonadherence is the so-called “MTX-intolerance.” It is a constellation of nonspecific symptoms usually classified as “associative,” “anticipatory” or “behavioural.”,, The cause of MTX intolerance is not known, but it could be related to increased intra- and extra-cellular levels of adenosine the main active anti-inflammatory molecule, in particular through its action on adenosine receptors in the central nervous system, which is largely due to antagonism of the action of endogenous adenosine at A1-and A2a-receptors in the central nervous system. Based on this, mechanism Joel Kremer had suggested the use of “a few extra cups of coffee” to offset MTX-intolerance. Taking the cue from that, a small study showed that a significant proportion of patients got relief with a schedule of coffee intake synchronized with MTX. On similar lines, the present communication reports the effect of coffee intake for relieving MTX intolerance in a much larger number of patients.
The present study included a total of 410 patients; 396 (96.58%) with RA, 4 (0.97%) with spondyloarthritis, and others 10 (1.21%) others (undifferentiated connective tissue diseases, systemic lupus erythematosus Sjögren's). All the patients were receiving a weekly dose of MTX (maximum 25 mg/week). To improve the MTX-adherence, the standard recommendations were followed, i.e., splitting the oral MTX dose at >15 mg/week, or switching to subcutaneous route, and folate supplementation. The severity of the intolerance was measured on a standard 0–100 numeric rating scale with 21 small circles from 0 to 100, at 5 unit increments. Of the 410 patients, 212 (51.7%) had minimal MTX intolerance not requiring any intervention (<10% intolerance), 198 (48.29%) patients had moderate-severe MTX intolerance (>10%). The latter was advised to take strong coffee synchronized with the MTX-dose as follows: Two cups early in the morning on the day of MTX, another two cups 2–3 h before the dose of MTX taken late in the evening. A 3rd dose of two cups was repeated the next morning with breakfast. This schedule was repeated every week synchronized with the weekly dose of MTX. In those with severe MTX-intolerance, palonosetron 0.5 mg tablets, 1 tablet 30 min before the MTX dose, repeated after 12 h, was advised. In addition, the patients were intensely counseled, explaining the importance of MTX in the treatment of their ailment and the proven efficacy of caffeine (in the form of coffee). The results were as follows [Table 1]:
A total of 103 (52.02%) patients who had relief with coffee were fond of coffee so, continued taking it for >1 year. Another 63 (31.81%) patients who had relief with coffee intake felt no need of it after 3–6 months, so stopped taking it and remained free of symptoms. Nine patients (4.54%) did not like taking coffee, gave it up immediately and managed MTX-intolerance with a variety of home remedies (including chocolates [contains small amounts of caffeine], sweet candies, anti-emetics, and avoiding a few meals). Twenty-three (11.61%) patients did not try coffee for the various reasons, and somehow managed the problem of MTX-intolerance.
Thus, the above results tend to confirm an earlier observation that caffeine (in the form of coffee) reduces the intolerance to MTX and improves the compliance rate. It would now require a properly controlled double-blind trial using natural coffee in “the intervention arm” and decaffeinated coffee in the “placebo arm” to prove or disprove the efficacy of caffeine (as a natural coffee drink) in offsetting MTX intolerance.
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Conflicts of interest
There are no conflicts of interest.
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