P089 A pilot study to consider implementing a validated tool to improve the objective assessment method of methotrexate intolerance for a paediatric rheumatology department
Authors: Tranter Catherine 
Published: April 2023

Abstract

Background/Aims
This report identifies if the adoption of the Methotrexate Intolerance Severity Score improves the documentation and objective evaluation of the experiences of patients with Juvenile Idiopathic Arthritis, currently treated with methotrexate within in a local paediatric rheumatology service. In doing so, it will evidence any treatment failure resulting in a change of therapy, including the advocated escalation to more expensive and invasive biological therapies.

Methods
Literature was retrieved from electronic databases and published guidelines. Stakeholders were identified and approached via a variety of methods. Using the claims, concerns and issues framework to document their findings, a pilot study implementing the validated methotrexate intolerance severity score was conducted. The parents of the first ten patients accessing the local paediatric rheumatology advice line within a twelve-week period, who wished to discuss their child’s methotrexate therapy, were interviewed by the clinical nurse specialist team according to the methotrexate intolerance severity score. Analysis of the ten telephone assessments included the patient pharmacological and haematological evidence already established for each child, previous documentation of any methotrexate intolerance, and previous awareness of potential side effects of this drug therapy

Results
Designed without key stakeholder input, the methotrexate intolerance severity score improved documentation but focused on the gastrointestinal symptoms of intolerance only. The results of this pilot project indicated that although nausea and vomiting remained the two most common problems identified by all three key stakeholder groups (the parents, the CNS team and the original MISS article), it failed to objectively record a number of other commonly experienced signs and symptoms attributed to methotrexate treatment, assessing intolerance using only four of the nine most commonly reported side effects. Crucially it also failed to consider the pharmacokinetic and toxicity profile of methotrexate, nor did it have capacity to document a range of other parent reported symptoms. Although published in 2011, it has yet to be adopted for regular use within the UK paediatric rheumatology services.

Conclusion
Further work is required; inclusion of the objective findings that contribute to and mimic methotrexate intolerance e.g., hepatotoxicity should be considered in addition to further research regarding the patient experience of methotrexate intolerance. Incorporating the experiences of the patients and families would contribute to the relevance of the methotrexate intolerance severity score to key stakeholders. Resulting in a more objective assessment tool, this would improve measurement of methotrexate intolerance, ultimately quantifying intolerance and access to biologic therapies and improve the clinical comprehension of the patient experience of this ‘gold standard’ disease modifying anti-rheumatic drug therapy.
Disclosure
C. Tranter: None.