Use of a psychotherapy method effectively reduces symptoms of methotrexate (MTX) intolerance in patients with juvenile idiopathic arthritis (JIA), according to German researchers.
The study, “Successful treatment of methotrexate intolerance in juvenile idiopathic arthritis using eye movement desensitization and reprocessing – treatment protocol and preliminary results,” was published in the journal Pediatric Rheumatology.
Methotrexate is the standard medication for children with JIA. Although safe, treatment with low-dose methotrexate may lead to intolerance to the drug, causing anticipatory nausea and refusal to take the medication.
EMDR (Eye Movement Desensitization and Reprocessing) is an eight-phase psychotherapy approach that’s been shown to be effective in the treatment of post-traumatic stress disorder (PTSD), trauma in children and adolescents, as well as post-operative pain.
The method consists of standardized procedures using a healthy and intensive recall of memories while applying bilateral eye stimulation, usually eye movements. With this technique, EMDR creates positive associations which reduce stress and reduce negative thoughts or worries linked with traumatic memories.
The researchers hypothesized that methotrexate intolerance may be a repetitive stressful or even traumatic event which could lead to anticipatory responses that prevent normal information processing. This made them develop an EMDR protocol as a potential treatment for methotrexate intolerance in JIA patients.
A total of 18 patients ages 8-17 were included in the study. Methotrexate intolerance was assessed with a standardized questionnaire before treatment, right after treatment, and four months after treatment. Health-related quality of life (HRQoL) was also evaluated before and four months after treatment.
Patients were intolerant to methotrexate if they scored at least six points in the questionnaire, including at least one anticipatory, associative or behavioral symptom, including restlessness, irritability, refusal to take methotrexate, abdominal pain, nausea, and vomiting.
The adapted EMDR protocol was based on eight treatment sessions over two weeks.
Treatment began with phase 1, an assessment of the patients’ psychosocial and medical history, including traumatic memories, and the development of their intolerance to methotrexate.
A subsequent exercise, phase 2, addressed patients’ anxiety, using slow bilateral stimulation while the patients were instructed to envision a place where they felt at peace.
The following five sessions (phases 3 to 7), which lasted 60 minutes each, were conducted over 10-12 days. They concluded with phase 8, the administering of methotrexate with no therapist present.
A final session was aimed at emphasizing the positive experiences related to EMDR and reprocessing a worst-case scenario to minimize anticipatory anxiety.
Results showed a significant improvement of symptoms, with no patient showing methotrexate intolerance right after treatment. But at four months, the methotrexate intolerance reoccurred in nine out of 18 patients (50%).
“MTX [methotrexate] intolerance in children with JIA was effectively treated using an EMDR protocol, with lasting effect over a period of 4 months,” the researchers wrote.
As for the re-occurrence of symptoms, researchers believe that follow-up treatment sessions and educating parents about EMDR may help improve results.
The data also showed that EMDR improved patients’ health-related quality of life at four months after treatment, especially their physical health.
“This either results from MTX [methotrexate] intolerance being experienced primarily as a physical phenomenon by the affected patients or EMDR treatment having a more pronounced effect on the physical sensations of MTX intolerance,” researchers wrote.
The team said additional studies should evaluate the long-term effectiveness of the MTX treatment approach, if re-treatment is necessary, and if the answer is yes, in what format?