{\rtf1\ansi\ansicpg1252\uc1 \deff0\deflang1033\deflangfe1033{\fonttbl{\f0\froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f2\fmodern\fcharset0\fprq1{\*\panose 02070309020205020404}Courier New;}
{\f3\froman\fcharset2\fprq2{\*\panose 05050102010706020507}Symbol;}{\f14\fnil\fcharset2\fprq2{\*\panose 05000000000000000000}Wingdings;}{\f28\fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}
{\f184\froman\fcharset238\fprq2 Times New Roman CE;}{\f185\froman\fcharset204\fprq2 Times New Roman Cyr;}{\f187\froman\fcharset161\fprq2 Times New Roman Greek;}{\f188\froman\fcharset162\fprq2 Times New Roman Tur;}
{\f189\froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f190\froman\fcharset178\fprq2 Times New Roman (Arabic);}{\f191\froman\fcharset186\fprq2 Times New Roman Baltic;}{\f200\fmodern\fcharset238\fprq1 Courier New CE;}
{\f201\fmodern\fcharset204\fprq1 Courier New Cyr;}{\f203\fmodern\fcharset161\fprq1 Courier New Greek;}{\f204\fmodern\fcharset162\fprq1 Courier New Tur;}{\f205\fmodern\fcharset177\fprq1 Courier New (Hebrew);}
{\f206\fmodern\fcharset178\fprq1 Courier New (Arabic);}{\f207\fmodern\fcharset186\fprq1 Courier New Baltic;}{\f408\fswiss\fcharset238\fprq2 Calibri CE;}{\f409\fswiss\fcharset204\fprq2 Calibri Cyr;}{\f411\fswiss\fcharset161\fprq2 Calibri Greek;}
{\f412\fswiss\fcharset162\fprq2 Calibri Tur;}{\f415\fswiss\fcharset186\fprq2 Calibri Baltic;}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;
\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;}{\stylesheet{
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs22\lang2057\langfe1033\loch\f28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 \snext0 Normal;}{\*\cs10 \additive Default Paragraph Font;}{
\s15\ql \li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 \fs22\lang2057\langfe1033\loch\f28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 \sbasedon0 \snext15 List Paragraph;}}{\*\listtable
{\list\listtemplateid1285852800\listhybrid{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807567\'02\'00.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li720 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807577\'02\'01.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li1440 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807579\'02\'02.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-180\li2160 }{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807567\'02\'03.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li2880 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807577\'02\'04.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li3600 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807579\'02\'05.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-180\li4320 }{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807567\'02\'06.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li5040 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807577\'02\'07.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-360\li5760 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807579\'02\'08.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 
\chshdng0\chcfpat1\chcbpat1 \fi-180\li6480 }{\listname ;}\listid396516976}{\list\listtemplateid-777382374\listhybrid{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace360\levelindent0{\leveltext
\leveltemplateid134807553\'01\u-3913 ?;}{\levelnumbers;}\f3\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li720 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807555\'01o;}{\levelnumbers;}\f2\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li1440 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807557\'01\u-3929 ?;}{\levelnumbers;}\f14\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li2160 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807553\'01\u-3913 ?;}{\levelnumbers;}\f3\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li2880 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807555\'01o;}{\levelnumbers;}\f2\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li3600 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807557\'01\u-3929 ?;}{\levelnumbers;}\f14\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li4320 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807553\'01\u-3913 ?;}{\levelnumbers;}\f3\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li5040 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807555\'01o;}{\levelnumbers;}\f2\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li5760 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807557\'01\u-3929 ?;}{\levelnumbers;}\f14\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li6480 }{\listname ;}\listid713232517}{\list\listtemplateid70788208\listhybrid{\listlevel\levelnfc0\levelnfcn0\leveljc0
\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807567\'02\'00.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li720 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0
\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807577\'02\'01.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li1440 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0
\levelstartat1\levelspace0\levelindent0{\leveltext\leveltemplateid134807579\'02\'02.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-180\li2160 }{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow0\levelstartat1
\levelspace0\levelindent0{\leveltext\leveltemplateid134807567\'02\'03.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li2880 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0
\levelindent0{\leveltext\leveltemplateid134807577\'02\'04.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li3600 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0\levelstartat1\levelspace0\levelindent0
{\leveltext\leveltemplateid134807579\'02\'05.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-180\li4320 }{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807567\'02\'06.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li5040 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807577\'02\'07.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-360\li5760 }{\listlevel\levelnfc2\levelnfcn2\leveljc2\leveljcn2\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext
\leveltemplateid134807579\'02\'08.;}{\levelnumbers\'01;}\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1 \fi-180\li6480 }{\listname ;}\listid1102186005}}{\*\listoverridetable{\listoverride\listid1102186005\listoverridecount0\ls1}
{\listoverride\listid396516976\listoverridecount0\ls2}{\listoverride\listid713232517\listoverridecount0\ls3}}{\info{\title Methotrexate (A case based on experience)}{\author Peter}{\operator Chris}{\creatim\yr2008\mo9\dy26\hr14\min41}
{\revtim\yr2008\mo9\dy26\hr14\min41}{\version3}{\edmins1}{\nofpages1}{\nofwords265}{\nofchars1513}{\*\company TOSHIBA}{\nofcharsws1858}{\vern8283}}\paperw11906\paperh16838\margl1440\margr1440\margt567\margb567 
\widowctrl\ftnbj\aenddoc\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\formshade\horzdoc\dgmargin\dghspace180\dgvspace180\dghorigin1440\dgvorigin567\dghshow1\dgvshow1
\jexpand\viewkind1\viewscale100\pgbrdrhead\pgbrdrfoot\splytwnine\ftnlytwnine\htmautsp\nolnhtadjtbl\useltbaln\alntblind\lytcalctblwd\lyttblrtgr\lnbrkrule \fet0\sectd \linex0\headery709\footery709\colsx708\endnhere\sectlinegrid360\sectdefaultcl 
{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}{\*\pnseclvl5
\pndec\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang
{\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \qc \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs22\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {\fs36 \hich\af28\dbch\af28\loch\f28 Methotrexate (\hich\af28\dbch\af28\loch\f28 A c\hich\af28\dbch\af28\loch\f28 ase based on \hich\af28\dbch\af28\loch\f28 experience
\hich\af28\dbch\af28\loch\f28 )
\par }\pard \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs24 \hich\af28\dbch\af28\loch\f28 
You are the only doctor in the surgery at lunch time, the Practice Nurse has just seen Tom McInes a hill farmer from a farm near to Fangdale\hich\af28\dbch\af28\loch\f28  Beck (15 miles or\hich\af28\dbch\af28\loch\f28 
 30 minutes from Great Ayton by aged land rover defender\hich\af28\dbch\af28\loch\f28 ). He has a harvest to bring in right now and needs his methotrexate prescription, the nurse has just taken his regular blood tests\hich\af28\dbch\af28\loch\f28 , 
\hich\af28\dbch\af28\loch\f28 and he\hich\af28\dbch\af28\loch\f28  has almost run out and doesn\hich\f28 \rquote \loch\f28 t have time to come back in the next few days.
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\langnp2057 \hich\af28\dbch\af28\loch\f28 1.\tab}}\pard\plain \s15\ql \fi-360\li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0 
\fs22\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {\fs24 \hich\af28\dbch\af28\loch\f28 Ar\hich\af28\dbch\af28\loch\f28 e you willing to give the prescription\hich\af28\dbch\af28\loch\f28 ?\line 
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\langnp2057 \hich\af28\dbch\af28\loch\f28 2.\tab}\hich\af28\dbch\af28\loch\f28 Do you want to discuss anything in particular with the Practice Nurse
\par }\pard\plain \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs22\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {\fs24 \hich\af28\dbch\af28\loch\f28 Answers:
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af3\hich\af3\dbch\af28\langnp2057 \loch\af3\dbch\af28\hich\f3 \'b7\tab}}\pard\plain \s15\ql \fi-360\li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin720\itap0 
\fs22\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {\fs24 \hich\af28\dbch\af28\loch\f28 For what condition does he take methotrexate? \line 
(Commonest reason in Primary Care is Rheumatoid Arthritis; dose usually 7.5mg taken once }{\fs24\ul \hich\af28\dbch\af28\loch\f28 weekly}{\fs24 \hich\af28\dbch\af28\loch\f28 , maximum weekly dose 20mg. Wher\hich\af28\dbch\af28\loch\f28 e as in Crohn
\hich\f28 \rquote \loch\f28 s Disease dose is 15-25 mg weekly. Prescribed as 2.5mg yellow tablets)\line 
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af3\hich\af3\dbch\af28\langnp2057 \loch\af3\dbch\af28\hich\f3 \'b7\tab}}\pard \s15\ql \fi-360\li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin720\itap0 {\fs24 
\hich\af28\dbch\af28\loch\f28 Is he stabilised on treatment?\line \hich\af28\dbch\af28\loch\f28 (Bloods before treatment, weekly until stabilised and 3 monthly there after)\line 
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af3\hich\af3\dbch\af28\langnp2057 \loch\af3\dbch\af28\hich\f3 \'b7\tab}\hich\af28\dbch\af28\loch\f28 If stabilised has he had normal full blood count, renal funct\hich\af28\dbch\af28\loch\f28 
ion and liver function tests in the last 3 months\hich\af28\dbch\af28\loch\f28 ?\line (CSM advice risk of blood dyscrasia and liver cirrhosis even with low dose methotrexate)\line 
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af3\hich\af3\dbch\af28\langnp2057 \loch\af3\dbch\af28\hich\f3 \'b7\tab}}\pard \s15\ql \fi-360\li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin720\itap0 {\fs24 
\hich\af28\dbch\af28\loch\f28 How old is he; has he had kidney problems and is he on any other medication (age, impaired renal function and anti-\hich\af28\dbch\af28\loch\f28 folate drugs all increase the risk of \hich\af28\dbch\af28\loch\f28 
haematopoietic\hich\af28\dbch\af28\loch\f28  suppression)\line 
\par {\listtext\pard\plain\s15 \lang2057\langfe1033\loch\af3\hich\af3\dbch\af28\langnp2057 \loch\af3\dbch\af28\hich\f3 \'b7\tab}}\pard \s15\ql \fi-360\li720\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin720\itap0 {\fs24 
\hich\af28\dbch\af28\loch\f28 Has he recently had any breathing problems or a cough (methotrexate can have pulmonary toxicity)\line 
\par }\pard\plain \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs22\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {\fs24 \hich\af28\dbch\af28\loch\f28 
N.B. Methotrexate is an amber drug, if all the above questions were satisfactory a prescrip\hich\af28\dbch\af28\loch\f28 tion could be given as long as the blood results were checked by the prescribing doctor when they are available.
\par }\pard \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs24 \hich\af28\dbch\af28\loch\f28 If the above questions raise any problems amber drugs are only prescribed \hich\af28\dbch\af28\loch\f28 
with specialist support so it should be easy for the GP to access fur\hich\af28\dbch\af28\loch\f28 ther advice before considering prescribing
\par }}