If you look carefully you will find you have a few patients with a prescription for the medication methotrexate and 

sulfasalazine. 

They were originally used as anti-cancer drugs for metastasis as they reduce your ability to make new cells. 

Now they are used as a treatment for autoimmunity for conditions such as RA, AS, Crohns disease, psoriasis and so on. 

But the effect on our ability to make new cells remains even with the lower doses used for autoimmunity. 

The issue here is around the ability to make the active form of folate or 5 MTHF. 

Note, folic acid is not the same as folate. 

We have discussed this before.

 

Folic acid is an inactive, man-made substance that must be converted through multiple steps into the active form 5MTHF.

Note, the red boxes are enzymes making the chemical conversion, orange at the end is active folate (5MTHF), which helps you make new cells – think red blood cells, hence low folate can give you anaemia.  

Note that the first enzyme is saturated at 200 mcg of folic acid, which is a small dose, most supplements are 400 mcg.

It is the unmetabolised folic acid that can cause issues detailed in the article above. 

This whole process is part of METHYLATION, a wickedly complex thing that is taught badly, but not by me. 

Below is a super quick and easy 2 minute video 👇

Here is roughly what it does it makes new stuff or turns stuff on, just really important stuff, like MYELIN: 

 And if you don’t do that, you also get rasied HOMOCYSTEINE, a modifable risk factor for dementia, fractures, CVD, strokes and all bad things:

But think about this, red blood cells last 4 months, while your cells of the mouth/gut live only 3-5 days. 

So, the mouth/gut will often complain first if you get less active folate and thus methylation thus reduced ability to make new cells. 

Let us go back to methotrexate and sulfasalazine, how do they fit in? 

Check out how they stop cells being made 👇

They stop you making the active form of FOLATE/5-MTHF. 

Less of that = less METHYLATION. 

And that means methotrexate and sulfasalazine, are notorious for giving side effects. 

Now, the NHS is well aware of this and if you ask those patients on these drugs if they are taking anything from the NHS to help, they will say “folic acid”. 

But, they give HUGE doses. 

It is not uncommon to give 5000 mcg (5 mg) in one go. 

Remember the RDA is 200 mcg and the enzyme that turns folic acid into the next metabolite, is saturated at 200 mcg. 

Reminder 👇

But, of course, methotrexate and sulfasalazine, are inhibiting those, so it is even less. 

Hence, the NHS tries to mega-dose the patients into more methylation. 

Unfortunately, it doesn’t work that well after a period of time in many. 

And the side effects of the drugs often begin to build up.

Patients may mention a non-specific methotrexate “brain fog” that is commonly known about. 

But, it isn’t a drug side effect directly, it is in reality, the symptoms of less METHYLATION and more HOMOCYSTEINE, which is toxic and inflammatory. 

So, if we can give the patient more active folate, to bypass the blockage from the medication, then maybe the “side-effects” will go away? 

And, my little neuro-mechanical friends, that is exactly what happens. 

Mrs W, is a long term-patient of mine, probably over 10 years under care

She came in via her mother in law, for some neuro-mechanical issues. 

And she also had psoriasis. 

At the time, I did mention that I had previously had psoriasis and was in remission, but she was not interested. 

Then a few years later, she started to get achy, really achy, in the hands. 

And was diagnosed with psoriatic arthritis. 

I once again mentioned my remission, and she politely declined any advice. 

She then began the long road of medication escalation. 

Each drug works for a while, then seems to fade, and they give new ones. 

And, eventually, she is on both methotrexate and sulfasalazine, plus of course mega-dose folic acid 5000 mcg (5mg), sometimes daily sometimes once a week. 

I continue to care for her, it is somewhat palliative, but I keep her spine in reasonable order as she lives her life. 

She then began to report some really broad aches and pain all through the muscles, and fatigue/malaise, and general joint stiffness and pain that is not her psoriatic pain, which she mostly gets in her hands and feet and is of a different nature. 

It sounds more like a fibromyalgic type pain which is often due to neuro-inflamamtion and hyper-sensitivity in the nervous system. 

So, this time I try again and go for the angle on the activation of folic acid being an issue and this time she bites. 

Frankly, she is out of options, as they can’t give her many more drugs and my offer is simple and makes sense. 

I sent here the article from above and also 👇

And she gets it.

I suggest she try 800 mcg active folate/5MTHF plus supporting METHYLATION nutrients. 

The response is quite staggering. 

Her energy is up, her vitality is back, her aches and pains are gone and her ROM is up. 

In hindsight, I was hesitant to mention the folic acid conversion thing as she had been so un-willing to look at anything non-NHS approved. 

But, the changes have made me talk to all my patients on these drugs and suggest a trial of METHYL B HERO. 

It is also important to explain that the folic acid from the GP/consultant is not special in anyway – is just the same as the shop bought stuff but more of it. 

And ideally, they should stop this for the duration of the months trial – if they look hesitant, leave it, but if they get a positive change, then they need to stop it. 

This all reminds me of a newsletter from years ago, check it

Patient centered means respecting the patients’ rights even when you might know it is not in their best interests. 

I hung in there and was able to really help her.

Could we have stopped the psoriatic arthritis? Possibly, but that was not her path, and I have had to accept that my path is often very different to others.