Soon after she started taking the drug methotrexate in February, Jennifer Crow noticed a significant improvement in her inflammatory arthritis pain. Since then, she’s taken the drug weekly. So her stomach dropped on July 1, when she got an automated call from her pharmacy saying her methotrexate refill for the month hadn’t been approved.
Crow, who is 48 and lives in Tennessee, was confused by the disruption, until she saw on social media that other people were reporting similar denials. Methotrexate—which in high doses is used as a chemotherapy drug—is sometimes prescribed to induce abortions, complicating its use in states that have restricted abortion access in the aftermath of Roe v. Wade being overturned.
Crow eventually did get her medication after her doctor re-processed the refill request, but she says temporarily going without it caused her pain and fatigue to flare up—and made her nervous about the future. While neither Crow’s doctor nor her pharmacy explicitly said that methotrexate’s link to abortion affected her prescription, she feels the timing is suspicious. Her home state of Tennessee currently forbids most abortions after about six weeks of pregnancy and is set to implement a near-total abortion ban next month.
Crow hopes that, moving forward, pharmacies will have clearer policies about how to handle non-abortion-related methotrexate prescriptions. But if not, “we’re going to be test cases,” she says. “That still worries me.”
Methotrexate is an antimetabolite, a class of drug that suppresses certain cellular functions, which is often administered orally or by injection. It’s approved by the U.S. Food and Drug Administration to treat some cancers, but it’s also commonly used for conditions including lupus, arthritis, and psoriasis. Doctors also use it to end ectopic pregnancies, in which a fertilized egg grows outside the uterus, resulting in an unviable pregnancy that carries the risk of life-threatening complications for the pregnant person. Methotrexate ends the pregnancy by preventing cells from dividing.
While methotrexate is not one of the drugs typically used in an elective medication abortion—those drugs are mifepristone and misoprostol—it can be used for that purpose. Pregnant people are advised not to take methotrexate because it may cause serious harm to the fetus.
Some states, like Texas, have laws that specifically list methotrexate as an abortion-inducing drug, placing restrictions on its use. Texas’ law does note, however, that such drugs are prescribed for non-abortion-related reasons that are exempt from those regulations.
Other states make similar distinctions. In Kentucky, a “trigger” law banned nearly all abortions in the state after Roe v. Wade was overturned, though that policy is now tied up in court. But on July 1, the Kentucky Board of Pharmacy emailed pharmacists and pharmacy interns in the state to remind them that, under Kentucky state law, “if a pharmacist receives a prescription and it doesn’t say, ‘for the induction of abortion,’ they can assume that it’s not for abortion,” explains executive director Christopher Harlow. This means pharmacists may fill prescriptions for drugs like methotrexate normally, if there’s no indication that it’s meant for abortion.
Harlow says the board has not received any reports of patients being denied prescriptions. But other organizations say they have.
“We have heard of a handful of cases of patients being completely denied [prescriptions] simply because they’re of childbearing age,” says Steven Newmark, director of policy at the Global Healthy Living Foundation, a nonprofit that supports people with chronic illnesses. Other patients have been told they “need to go back to their doctor, or the pharmacist has to check with the doctor, or the doctor is being wary and more reluctant” to prescribe drugs like methotrexate, Newmark says.
Michael Murphy, advisor for state government affairs at the American Pharmacists Association, says pharmacists may be reluctant to fill methotrexate prescriptions if they practice in states where providers can be held legally or financially liable for performing abortion services. Laws vary quite a bit from state to state, and many leave enough gray area that it’s not always obvious when or how someone could be liable.
It’s also not clear how many patients have been denied methotrexate, though a number of people have shared their experiences on social media. Several health groups—including the Lupus Foundation of America, Arthritis Foundation, and American College of Rheumatology—recently posted statements about reported access issues and told patients to contact them if they ran into problems.
Murphy says reports of patients being denied methotrexate are anecdotal, so it’s hard to get a handle on how common they are. But, he says, “any reports of patients not being able to receive their medications and maintain that continuity of their care is very concerning for us as pharmacists.”
Newmark says he hopes states will pledge to preserve access to these medications, hopefully before it becomes a widespread issue. “If things don’t get remedied quickly,” he says, “it’s going to require more action.”
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