Background/Purpose: Methotrexate (MTX) forms the backbone of treatment for the majority of patients with rheumatoid arthritis (RA), and is advocated in most guidelines.^{[i],[ii],[iii]} Existing studies imply in as many as 21% of new patients oral MTX is either ineffective or not tolerated.^[iv],[v] In our clinical practice these patients are routinely prescribed subcutaneous (SC) MTX, which has demonstrated improved efficacy and tolerability over the oral formulation.^[vi],[vii]To identify outcomes of patients prescribed SCMTX, a retrospective audit was undertaken. 

Methods: All RA patients who had received SCMTX at the Royal Surrey County Hospital, Guildford were identified from medical records. Demographic data, reason for switch from oral to SCMTX, continuation rates, eventual requirement of biologic therapy and disease activity scores (DAS) were recorded. Data presented represents audit analysis to date. 

Results: We are presenting the first 102 RA patients who switched from oral MTX to SCMTX therapy. Average age of diagnosis was 50 years and 78% of patients were female. Mean duration of oral therapy was 8.8 years, at a mean weekly dose of 20.3 mg. Patients were switched from oral to SCMTX due to lack of efficacy (46%) or tolerability issues (27%). 43% of all patients were on at least two DMARDS and 12% were on three. Patients switching to SCMTX were given a mean weekly dose of 20.49 mg at initiation. The average duration of SCMTX therapy by time of analyis was 2.8 years. 87 patients thereafter remain on SCMTX either alone or in combination with other disease modifying antirheumatic drugs (DMARDs); treatment of 15 (14.7%) required escalation of therapy to include a biologic due to aggressive disease. Continuation rates for SCMTX were 94% at 1 year and 82% at 2 years, with only 8% of patients progressing to a biologic during the two years. In patients who required a biologic and SCMTX the continuation rate was 93% at 1 year and 92% at 2 years. DAS assessments were made over differing time periods, a subset of which was analysed and showed continued DAS improvement over time and a rise in significant improvement (ΔDAS28 >1.2) and remission rates (DAS <2.6).

Conclusion: The GEMS audit has confirmed efficacy and tolerability of SCMTX in patients after failing oral MTX either due to inefficacy or toxicity with high continuation rates and maintenance of disease activity control either with or without biologic therapy. These results further support our routine practice of switch of route of administration of MTX prior to the use of biologics without compromising patient care.