Bactrim antibiotic and MTX bad combo

[LoriASoCal]

Hi everyone,

I have a kidney infection and I went to urgent care and told them I was on remicade and mtx. The doctor on call prescribed, bactrim, luckily the pharmacist caught it. I did not know that these drugs interacted with each other so seriously. Later I looked it up and found several articles on it.

here is a link to one which also has other good information in it:

www.dermsociety.org/default. asp?id=3&aui=sa&aid=44 - 15k


Special Lecture - Psoriasis Treatment Pearls

Mark Lebwohl, M.D.
December 06, 2001
print version
email article



A 68 year-old man with 10% BSA psoriasis had failed treatment with a class I steroid, Dovonex, tazatotene, anthralin and had refused UVB.

Dr. Lebwohl suggested combination therapy, eg. combination of salicylic acid with a super potent topical corticosteroid. Ten percent salicylic acid with clobetosol propionate is dramatically more effective than the Class I steroid alone. Adding salicylic acid increases the efficacy and increases side effects. Make sure when a pharmacy compounds that the pharmacist uses salicylic acid powder and not aspirin.

When salicylic acid 6% is added to calcipotriene ointment, the calcipotriene is inactivated even if the pH is adjusted. Lachydrin inactivates calcipotriene, also. Estar gel and ultravate are completely compatible. Use of ultravate on weekends and Dovonex on weekdays works very well.

A 28 year-old woman lawyer with 40% BSA on methotrexate 15mg per week reports worsening of her psoriasis and arthritis. Options for treatment which were discussed included:


Increasing the MTX dose: a viable option.

Adding cyclosporine: a report in the JAAD in 1990 suggested not using MTX and cyclosporine together because MTX is hepatotoxic and cyclosporine is metabolized by the liver and cyclosporine is hepatotoxic and MTX is excreted by the kidney. Subsequently, it was shown that use of low doses of these agents together has fewer side effects with a decrease in hepatotoxicity of MTX and decreased hephrotoxicity of cyclosporine.

Adding Naproxen: will increase the MTX levels (as will salicyliates and ibuprofen). All also increase MTX toxicity. Also MTX increases naproxen levels and increases toxicity. Therefore, MTX and naproxen should never be used together. Feldene, orudis, and Ansaid do not increase MTX levels and are safe to use. Vioxx and Celebrex are also safe.

Add Azulfidine to methotrexate: Azulfidine does not raise MTX levels or increase toxicity. It increases the benefit marginally but these two are safe together.

Add Bactrim: Bactrim and MTX will increase MTX dramatically leading to death or neutropenia.

Enbrel and MTX is used in rheumatoid arthritis and will soon be used for psoriatic arthritis and hopefully psoriasis. The combination is better than methotrexate alone.

Folic Acid (5mg po QD) will decrease the megaloblastic anemia and nausea associated with MTX. Some beneficial effects of MTX are lessened.

[abbyroad]

Great information Lori! I hope you feel better soon!!

aloha,
Abby

[rosee_posey]

Yes, you are absolutely right. In fact, I remember Dr. Lebowohl saying that at an NPF conference two or three years ago, in fact.

I think he said "Bactrim is bad...you don't want to be taking that!!!" Death as a side effect is bad, now ain't it?

It's nice to know that you, your pharmacist, and the med database that he is using is up to date and "the database actually works!" Who knew?

Good job, and thanks for the heads up!

- rose

[ouchyk]

Wow, Lori,

Good catch by your pharmacist! Thank goodness. What are you taking for the infectiontion?


Feel better soon Lori,

Karen

[jennab711]

Does anyone have similar info re: cyclosporine. It is pretty much as strong of a med as MTX, and quite frankly, I have little idea what I should not take. All I know is grapefruit juice is a big NO. Other than that, I take advil, tylenol, Diflucan, whatever my dr prescribes. I figure they should know more than me what I can or cannot take.