Methotrexate Access Threatened by Abortion Laws Despite Lifesaving Uses

Methotrexate Use During Pregnancy

Methotrexate is a medication that has been used for decades to treat a variety of medical conditions including cancer, autoimmune diseases like rheumatoid arthritis, and ectopic pregnancies. However, with recent restrictions on abortion access in many states, there is growing concern about the ability for women to access methotrexate for legitimate medical needs not related to elective abortion.

What is Methotrexate?

Methotrexate is a chemotherapy drug that was originally developed in the 1940s as a treatment for cancer. It works by inhibiting folate metabolism which interferes with DNA synthesis and cell division. This mechanism makes methotrexate effective at killing rapidly dividing cancer cells. However, it also means the drug can be toxic to many normal tissues that undergo rapid cell division like bone marrow, skin, intestines, and fetal development.

In lower doses, methotrexate has immunosuppressive effects that have made it a standard treatment for autoimmune diseases like rheumatoid arthritis, lupus, and psoriasis. By suppressing the overactive immune system associated with these conditions, methotrexate can reduce inflammation and minimize damage to joints and organs.

Methotrexate also happens to be one of the medications recommended for resolving ectopic pregnancies along with the nearly identical drug misoprostol. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in one of the fallopian tubes. If left to progress, ectopic pregnancies will likely rupture the fallopian tube causing severe internal bleeding which can be fatal for the mother. Methotrexate or misoprostol can help break down and reabsorb the implanted embryo to resolve the dangerous ectopic pregnancy.

Methotrexate Access and Abortion Laws

Despite its many therapeutic uses, methotrexate has gotten caught up in the politics surrounding abortion access. In high doses, methotrexate has been used in some chemical abortion regimens. However, its primary use in pregnancy is for treating dangerous ectopic pregnancies which are never viable.

With the Supreme Court overturning Roe v. Wade in 2022, many states have enacted strict limits or bans on abortion access. There is concern these laws could also restrict access to methotrexate even when it is used for legitimate health reasons not related to elective abortion. Some states have unclear exemptions for "miscarriages" or "ectopic pregnancies" which does not recognize the medical reality that resolving an ectopic pregnancy requires termination of the implanted embryo before it can rupture the fallopian tube.

Several recent incidents highlight this issue:

• In Texas, a pharmacy refused to fill amethopterin, the brand name version of methotrexate, for a lupus patient over confusion whether it could be used for abortion.
• In Arizona, a rheumatoid arthritis patient was unable to get her regular refill of methotrexate due to the pharmacy's concerns about the state's near total abortion ban.
• A South Carolina patient with an ectopic pregnancy had lifesaving care delayed while her doctors sought legal advice about treating her with methotrexate due to ambiguity in the state's abortion law.

Medical experts warn that lack of clarity in abortion restrictions creates a chilling effect where physicians may hesitate to provide standard of care treatment. This could result in dangerous delays in access to time-sensitive medications like methotrexate.

Methotrexate Access for Rheumatoid Arthritis

Methotrexate access concerns disproportionately affect women because autoimmune diseases like rheumatoid arthritis occur more frequently in women. Methotrexate has been the cornerstone treatment for rheumatoid arthritis for decades because it is effective at reducing inflammation and slowing joint damage in this progressive autoimmune condition.

Rheumatoid arthritis causes immune cells to attack the lining of the joints leading to swollen, painful joints and eventual permanent joint destruction if left uncontrolled. Methotrexate works by suppressing overactive immune cells thereby reducing inflammation. When used regularly, it can minimize flare-ups and allow rheumatoid arthritis to enter remission.

For many rheumatoid arthritis patients, methotrexate has been transformational in allowing them to gain control over their symptoms and live full lives. Restricting or delaying access to the medication could have devastating quality of life consequences in addition to allowing progression of their disease.

Ectopic Pregnancy Treatment Delays

The most dangerous consequence of limited methotrexate access is for patients experiencing ectopic pregnancy. Ectopic pregnancies are rare but life-threatening complications of pregnancy where the embryo implants outside the uterus. While embryos cannot survive long-term implantation in areas like the fallopian tubes, they can grow large enough to rupture these delicate structures and cause massive internal bleeding.

Methotrexate and misoprostol work by breaking down the implanted embryo to resolve the ectopic pregnancy before rupture. If treatment is delayed, the likelihood of rupture and maternal death increases dramatically. Ectopic pregnancies account for the majority of deaths during the first trimester and the maternal mortality rate from a ruptured ectopic pregnancy is as high as 20 percent even with modern medical care.

Doctors emphasize there are no other alternatives if an ectopic pregnancy will not resolve on its own. Surgery to remove the embryo is also termination of pregnancy. The only options are methotrexate/misoprostol or watching the fallopian tube rupture leading to bleeding out which is far more dangerous and traumatic.

The Role of Pharmacies

Pharmacies have found themselves on the front lines of this issue with increasing reports of refused or delayed refills of methotrexate. Most states with abortion restrictions have vague language about "chemical abortion" that could be interpreted to include methotrexate in high doses. Additionally, many of these laws threaten criminal penalties for pharmacists which incentivizes refusing treatment in unclear situations.

Major pharmacy chains like Walgreens, CVS, Walmart, and Kroger have publicly stated they will continue filling methotrexate for ectopic pregnancy, miscarriage, cancer, and autoimmune disease treatment. However, individual pharmacists may make decisions counter to corporate policies when faced with criminal liability concerns.

Recent incidents highlight that even if the prescription indicates it is for rheumatoid arthritis or ectopic pregnancy, some pharmacists are unwilling to take the risk. This underscores the need for clarification in abortion laws that methotrexate prescribed in line with standard of care guidelines cannot lead to criminal prosecution.

Path Forward for Methotrexate Access

Medical groups including the American College of Rheumatology, American College of Obstetrics and Gynecology, and American Medical Association strongly urge lawmakers to clarify abortion restrictions should not impact methotrexate access for legitimate health needs. Regardless of personal views on elective abortion, restricting access to life-saving care for ectopic pregnancies and quality of life-improving treatment for chronic diseases helps no one.

Doctors recommend the following actions to ensure continued methotrexate availability:

• Pharmacies and pharmacy boards should reassure pharmacists that dispensing methotrexate under normal prescribing guidelines cannot lead to criminal prosecution.
• Lawmakers should add explicit exemptions in abortion laws for methotrexate use treating ectopic pregnancies, cancer, and autoimmune diseases like rheumatoid arthritis.
• The medical community should continue educating that ectopic pregnancies are never viable and require embryo termination for maternal saving.
• Patients should lobby lawmakers and speak out when experiencing barriers obtaining methotrexate for legitimate health needs.

Ensuring women undergoing dangerous ectopic pregnancies and patients suffering from chronic inflammatory conditions can promptly get prescribed methotrexate is imperative. Clarifying and publicizing that methotrexate access for non-elective abortion uses remains legal despite changing abortion laws will go a long way to avoid life-threatening treatment delays. Through education and advocacy, lawmakers, pharmacies, physicians, and patients can work together to ensure this vital medication remains available for those who truly need it.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.