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Methotrexate Dose Escalation
The first case was of a 55-year-old woman who presents with two months of morning stiffness, pain, and swelling in her hands and is found to have positive rheumatoid factor and cyclic citrullinated peptide antibodies. Dr. Ormseth polled the audience as to what would be the best initial treatment for this patient, and more than 60% responded correctly that this would be to initiate 15 mg of oral methotrexate weekly and increase by 5 mg every four weeks to a target dose of 20 to 25 mg weekly. This strategy is based on recommendations from the 2021 ACR Guideline for the Treatment of Rheumatoid Arthritis, in which initiation/titration of methotrexate to a weekly dose of at least 15 mg by four to six weeks is conditionally recommended over initiation/titration to a weekly dose of <15mg.1
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.