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Editor, – I refer to the interesting article 'Perils and pitfalls of methotrexate prescription' (Aust Prescr 2000;23:44-5) in which Dr Kanagarajah highlights the significant compliance problems that a prescriber should be aware of when using this therapy in elderly patients. Indeed, the increasing use of methotrexate is likely to centre on older patients, who may have concurrent multi-organ system impairments. Renal function is impaired in many of these patients, even though the serum creatinine remains in the normal range. A similar situation exists in other organ systems where reduced reserve function remains silent and subclinical until challenged and exposed by disease or medication.

Underlying deficits in haematological, nutritional (including folate) and immunological reserve may become overt when challenged with a potent immunomodulator such as methotrexate. A sinister danger is that, through the mechanism of convergence, where multiple system factors impact on key physical functions, an older person may not present with adverse effects usually ascribed to that drug, but rather with ailing function. The use of ever more powerful medications, aiming for symptom reduction in an ageing patient population, requires increasing levels of clinical awareness and prudence.

Tuly Rosenfeld
Senior Staff Specialist
Department of Geriatric Medicine
Prince of Wales Hospital