How Abortion Bans Are Affecting Access to Methotrexate, a Crucial Treatment for Autoimmune Disease

Abortion restrictions following the fall of Roe v. Wade have introduced some unexpected and harmful challenges for people with autoimmune diseases: Some patients have reported being unable to obtain the drugs necessary for treatment.

Methotrexate—a drug widely used to treat rheumatoid arthritis and cancer, among other chronic diseases—is at the center of this issue. The reason? Because in addition to treating autoimmune diseases, methotrexate can also be used to terminate a pregnancy.

"Unfortunately, arthritis patients who rely on methotrexate are reporting difficulty accessing it," the Arthritis Foundation said in a recent statement. "At least one state—Texas—allows pharmacists to refuse to fill prescriptions for misoprostol and methotrexate, which together can be used for medical abortions. Already there are reports that people in Texas who miscarry or take methotrexate for arthritis are having trouble getting their prescriptions filled."

And Texas isn't the only state with this issue; patients in several states—especially those that have laws or trigger laws intended to criminalize abortion—have reported difficulty accessing their medication, Alisa Vidulich, MPH, policy director at the Arthritis Foundation, an organization that works to advance research, do advocacy, and provide disease management support, told Health.

According to Vidulich, it's not yet clear how many patients are being affected by these bans. "We are still working to identify exactly how widespread the issue is, by state and by patient demographics," she said. "As more patients attempt to get refills down the road, we do anticipate more people reaching out to us."

But one thing is for certain: Any patients being denied access to their treatment plans are at risk for serious health consequences. "It is critical that our patients are able to maintain the continuity of that care, that they do not have a break in taking their prescription, as that could cause flare-ups as well as other disease-worsening effects," Vidulich said.

What Is Methotrexate?

Methotrexate is a versatile drug. In higher doses, it can be used as a cancer drug, since it works by slowing the growth of cancer cells. In smaller doses, the drug works by suppressing the immune system, making it a key treatment for autoimmune diseases like rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, lupus, and Crohn's disease.

For those who take the drug, methotrexate is a central part of their disease treatment. "Ninety percent of rheumatoid arthritis patients take this medication at some point," said Vidulich. "It is one of the first drugs that our patients are prescribed." According to the Arthritis Foundation, the drug also allows infants with juvenile idiopathic arthritis by "getting the disease into remission so the child can live a full and pain-free life."

Methotrexate may also be prescribed to treat an ectopic pregnancy—specifically an unruptured ectopic pregnancy— a condition in which a fertilized egg grows outside of the uterus, typically in a fallopian tube. If this pregnancy is not terminated, it can be a life-threatening condition. Methotrexate ends the pregnancy by stopping the cells from growing, according to the American College of Obstetricians and Gynecologists (ACOG). Once the pregnancy ends, the body absorbs it over the next few weeks.

When taken during pregnancy—but not for abortion purposes—it may cause severe birth defects, which makes it unsafe for pregnant or breastfeeding people. When doctors prescribe methotrexate to patients who may become pregnant (or to patients who may get a partner pregnant) they require consent to also use birth control methods.

Why Is Methotrexate Being Affected By Abortion Restrictions?

The fall of Roe put decisions regarding abortion restrictions back into the hands of the states—and each state has different laws.

In Texas, for example, methotrexate is cited as an example of an abortion-inducing drug. The Texas law does specify that the term "abortion-inducing drug" does not apply to medications that may be known to cause an abortion but are prescribed for other medical reasons. In other states, laws are less specific, amplifying the confusion and uncertainty among physicians and pharmacists.

"These are not government affairs professionals, lawyers, or policy experts. They are just health care providers trying to scrape together the information," Steven Schultz, director of state legislative affairs at the Arthritis Foundation, told Health.

"There is some fear around prosecution and persecution among medical professionals," said Vidulich. While they are not sure what to do, they may err on the side of caution by either refusing to fill a prescription or waiting for further clarification from their state Board of Pharmacy or their professional associations.

"If there is even a small chance that you might go to prison for dispensing a medication used in an abortion, then you're going to be very careful about it," pharmacist Donald Miller, PharmD, professor of pharmacy practice at North Dakota State University, told Health.

Schultz mentioned that the Kentucky Board of Pharmacy recently issued a clarification for pharmacists in the state noting that if a prescription doesn't specify that the drug will be used for the induction of abortion, they should assume that it is being prescribed for its indicated purpose—in the case of methotrexate, for example, for diseases like rheumatoid arthritis, lupus, psoriatic arthritis, and cancer.

Miller believes that states that have new restrictions on abortion will face the need to clarify their laws and all of the exceptions to them. "I think that when legislators write these kinds of laws, they have no clue about all the things that can happen in real-life practice."

Another issue, according to Vidulich, is that pharmacists in many states are technically and legally allowed to decline to fill a prescription based on their moral beliefs. "And only a handful of them would require referring the patient to another pharmacist who would fill that prescription," she said.

In addition to the fear of prescribing methotrexate and inadvertently breaking an abortion law, there is yet another reason health care providers might hesitate to prescribe that drug in a post-Roe world: That a woman will become pregnant while on methotrexate, which could necessitate an abortion.

"In the past, if you did become pregnant while on methotrexate, having an abortion would be an option," said Miller. "But now, if that's not an option in your state, it's going to make doctors very reluctant to prescribe methotrexate for a younger woman."

What to Do if You Have Trouble Accessing Methotrexate

To try to prevent problems in accessing methotrexate, patients may want to make sure their physician writes the indication for the medicine on the prescription. They may also talk to the pharmacists to clarify why they need that drug and, if the pharmacist still has questions, they may call the prescribing doctor. "There might be the odd case where a pharmacy absolutely refuses to fill a prescription," said Miller. "In which case, you'd have to try another pharmacy or even a mail-order pharmacy if needed," But, he added, those cases should be rare.

To further help, chronic illness foundations and patient advocacy groups are using their resources to help people who take methotrexate for disease management and are running into issues obtaining the drug.

The Arthritis Foundation offers a helpline for patients experiencing issues—they may contact the organization through the number 1-800-283-7800. "There are trained and licensed clinical staff, including a Spanish-speaking expert, and patients can remain anonymous. So, we encourage patients who are having any trouble or who are confused or just need to speak with someone to call our helpline," said Vidulich.

The American College of Rheumatology also stated that it has assembled a task force of medical and policy experts to determine the best course of action for ensuring our patients keep access to the treatments they need. In the meantime, they asked members and patients who have had problems accessing methotrexate to email advocacy@rheumatology.org with details.

The Crohn's & Colitis foundation too has offered up their help: the organization requests patients who have been unable to get methotrexate reach out to their advocacy group (advocacy@crohnscolitisfoundation.org) or to contact the organization's help center by emailing info@crohnscolitisfoundation.org or calling 1-888-MYGUTPAIN.