Methotrexate Access Becomes Challenging for Some Patients Following Supreme Court Decision on Abortion

In an interview with Pharmacy Times, Donald Miller, PharmD, discussed how the recent Supreme Court decision overturning Roe v. Wade has created confusion around access to methotrexate for patients in some states that are limiting abortion access. Although methotrexate is commonly used for rheumatoid arthritis and a host of autoimmune diseases, it can be used to treat ectopic pregnancy. Although Miller said pharmacists should know their patients’ diagnoses and should be able to counsel them on their routine methotrexate use, the restrictions in some states have left patients and providers unsure about whether methotrexate can be dispensed in some cases.

Donald Miller, PharmD: Now states can pretty much do whatever they want. So, obviously, a number of states have banned or very soon will have a ban on abortion in almost all circumstances. For a pharmacist to dispense a medication that could be used in abortion puts them at some legal risk. Methotrexate usually is not thought of as an abortion drug, but it is sometimes used to treat an ectopic pregnancy. Both physicians and pharmacists, now, are afraid to give it out, especially to any young female patients.

Aislinn Antrim: Outside of the use for abortion, can you talk about what it is mostly used for? And why that access is so important?

Donald Miller, PharmD: It’s used especially for rheumatoid arthritis because it’s really just a mainstay disease-modifying drug for almost everyone who develops rheumatoid arthritis. It’s also used in a lot of autoimmune diseases, psoriasis, psoriatic arthritis, lupus, inflammatory bowel disease, among others. So it does affect quite a few people. That probably is not a first-line drug for most of those, other than rheumatoid arthritis.

Aislinn Antrim: From what you’ve heard so far, how are pharmacists handling this issue if they’re in a state where this is restricted?

Donald Miller, PharmD: I think it’s all over the board. I’ve read lots of stories about this too. It seems like even in some states that don’t restrict abortion, pharmacies and physicians are becoming very careful. I’m sure there’s also a lot of pharmacists just dispensing it routinely. But certainly, there’s fear, and well-documented, at least some pharmacies are refusing to fill prescriptions. Also, some doctors or even whole medical systems apparently have put a hold on prescribing methotrexate until they get more clarity on what they can and can’t do.

Aislinn Antrim: Can you discuss how pharmacists are being potentially impacted? There are liability concerns. There’s also just the toll it takes not being able to care for patients the way you normally would.

Donald Miller, PharmD: It’s got to be stressful, in a lot of ways. A lot of it is confusion, I think, whether it’s a medical system, doctor, pharmacist. It’s like, I don’t know what I can do and what I can’t do. And if I do the wrong thing, I could go to jail, or nevermind even that, if I do the wrong thing, I could be accused of participating in an abortion, which affects your reputation. It would be nice to just sit it out for a couple of months, let everything settle down, but our patients need methotrexate right now. I’m hoping that most pharmacists are simply using their professional judgment and continuing to dispense methotrexate appropriately.

Aislinn Antrim: Have you heard of any litigation efforts or other ways that that people are helping or trying to clarify the confusion?

Donald Miller, PharmD: I think there’s going to be a lot of litigation. But unfortunately, sometimes these things don’t get resolved until there’s actually a case. I think it’s almost inevitable—some people are going to be accused of dispensing an abortifacient and it’s going to go to a trial or something. And it’ll be settled either in courts with precedents. But hopefully—this is going take some time—everyone’s contacting their legislators and their different states, try to get [LM1] any clarity. A lot of these abortion laws were passed, I think, probably pretty quickly. This was the idea that we don’t want abortion at all. Legislators didn’t think at all about all the medical implications, and so I would think that there would be, eventually, some further legislation in many states that would create some safe harbors. But legislative sessions don’t meet all the time, could be a year or 2 years before that’s figured out. And again, case law would take a while. I think we’re going to be kind of a mess for quite a while.

Aislinn Antrim: Are there any more immediate actions that pharmacists could take or their patients could take to ensure access to methotrexate or to talk to legislators? Anything else you would encourage?

Donald Miller, PharmD: I think we all have to use professional judgment. Most pharmacists are probably just talking to the patient and/or talking to the prescribing physician to get clarity and get documentation of exactly what's being done. I think your best protection against any liability is always know your patient. Most of your patients on methotrexate have probably been on it for a long time. It shouldn't even be a question about the appropriateness, and again, prescribers, many of them, pharmacists will know. It shouldn't be an issue other than maybe your occasional brand new patient who's seeing a doctor you don't know, but you can still clarify. I think it's also very easy for retail pharmacy to recognize a suspicious prescription. Not only should you know many of your patients already, but the only time methotrexate is used for abortion is specifically for ectopic pregnancy. When it's used for ectopic pregnancy, it has to be used in a high dose by injection. The smaller doses that patients use for rheumatoid arthritis and so on won’t be effective with ectopic pregnancy. There's no way you can accumulate enough oral methotrexate to use it in an abortion or ectopic pregnancy, because a patient simply can't tolerate much more than 20-25 milligrams methotrexate at one time. To use it in an abortion or ectopic pregnancy, it has to be given by injection. Now, some of our patients also will get methotrexate by injection for rheumatoid arthritis. But again, that's at most probably 25 milligrams once a week. So, if someone was to divert that to her friend, they'd be giving up a month's worth of their own methotrexate. It just seems ridiculous that it would be trafficked or misused by any patient that you know of. I think a lot of the fear is way overblown. I think, again, if you use your professional judgment, do the same thing you do every day, I think pharmacists are going to be fine.

Aislinn Antrim: Is there anything you want to add anything that I didn’t think to ask about?

Donald Miller, PharmD: Well, the other thing that's kind of interesting is apparently physicians are also more reluctant to prescribe methotrexate for a young woman. It's always been a concern, because with methotrexate, it can cause birth defects if you become pregnant. If a young woman's taking methotrexate, she would need to be on birth control. Hopefully that works, but there’s always that chance that birth control will fail. Now, I think physicians are having to have really good talks, even more important talks with their patients—if they're taking methotrexate and they’re to become pregnant, that if you do become pregnant, abortion is no longer an option. You have to be really sure you want to use the medication. You have to be sure you're using a contraceptive appropriately.