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Prescott JD, Drake VJ, Stevens JF. Medications and Micronutrients: Identifying Clinically Relevant Interactions and Addressing Nutritional Needs. J Pharm Technol 2018; 34:216-230. [PMID: 34860982 PMCID: PMC6109862 DOI: 10.1177/8755122518780742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Objective: Prescription drug use is on the rise, and the use of dietary supplementation remains common. In the United States, more than half of all adults take a dietary supplement in any given month. As a result, drug-nutrient interactions are becoming an important consideration when pharmacists counsel patients about their drug regimens. We reviewed the literature to identify common and/or clinically relevant drug-nutrient interactions that pharmacists may encounter in practice. Data Sources: A MEDLINE search for English-language publications from 1970 through March 2017 was performed using search terms (and variations) related to drugs, medications, micronutrients, and interactions. Study Selection and Data Extraction: Relevant studies, case reports, and reviews describing drug-nutrient interactions were selected for inclusion. Data Synthesis: Some drug-nutrient interactions may result in micronutrient insufficiencies or even frank deficiencies, thereby necessitating augmentation with multivitamin/minerals or individual vitamin/mineral dietary supplements. This most often occurs with long-term therapy for chronic conditions, such as treatment with proton-pump inhibitors and histamine-2 receptor antagonists. In addition, some chronic diseases themselves, such as diabetes, may predispose patients to micronutrient insufficiencies, and dietary supplementation may be advisable. Conclusions: Drug-nutrient interactions can often be resolved through specific dosing strategies to ensure that the full effect of the medication or the dietary supplement is not compromised by the other. In rare cases, the dietary supplement may need to be discontinued or monitored during treatment. Pharmacists are in a key position to identify and discuss these drug-nutrient interactions with patients and the health care team.
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Abstract
PURPOSE OF REVIEW The purpose of this review was to give an update on treatment modalities for patients with idiopathic inflammatory myopathies, or shortly myositis, excluding the subgroup inclusion body myositis, based on a literature survey on therapies used in myositis. Few controlled trials have been performed in patients with myositis; therefore, we also included a summary of open-label trials, case series, and case reports. RECENT FINDINGS Glucocorticoid (GC) in high doses is still the first-line treatment of patients with myositis. There is a general recommendation to combine GCs with another immunosuppressive agent in the early phase of disease to better control disease activity and possibly to reduce the risk for GC-related side effects. Furthermore, combining pharmacological treatment with individualized and supervised exercise can be recommended based on evidence. There is some evidence for the effect of rituximab in patients with certain myositis-specific autoantibodies, whereas other biologic agents are currently being tested in clinical trials. SUMMARY Immunosuppressive treatment in combination with exercise is recommended for patients with myositis to reduce disease activity and improve muscle performance. Subgrouping of patients into clinical and serological subtypes may be a way to identify biomarkers for response to specific immunosuppressive and biological agents and should be considered in future trials.
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Affiliation(s)
- Simone Barsotti
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Ingrid E. Lundberg
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Solna, SE-171 76 Stockholm, Sweden
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53
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Methotrexate mechanism in treatment of rheumatoid arthritis. Joint Bone Spine 2018; 86:301-307. [PMID: 30081197 DOI: 10.1016/j.jbspin.2018.07.004] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/20/2018] [Indexed: 01/17/2023]
Abstract
Methotrexate has been used in treatment of rheumatoid arthritis (RA) since the 1980s and to this day is often the first line medication for RA treatment. In this review, we examine multiple hypotheses to explain the mechanism of methotrexate efficacy in RA. These include folate antagonism, adenosine signaling, generation of reactive oxygen species (ROS), decrease in adhesion molecules, alteration of cytokine profiles, and polyamine inhibition amongst some others. Currently, adenosine signaling is probably the most widely accepted explanation for the methotrexate mechanism in RA given that methotrexate increases adenosine levels and on engagement of adenosine with its extracellular receptors an intracellular cascade is activated promoting an overall anti-inflammatory state. In addition to these hypotheses, we examine the mechanism of methotrexate in RA from the perspective of its adverse effects and consider some of the newer genetic markers of methotrexate efficacy and toxicity in RA. Lastly, we briefly discuss the mechanism of additive methotrexate in the setting of TNF-α inhibitor treatment of RA. Ultimately, finding a clear explanation for the pathway and mechanism leading to methotrexate efficacy in RA, there may be a way to formulate more potent therapies with fewer side effects.
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Betancourt BY, Biehl A, Katz JD, Subedi A. Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheum Dis Clin North Am 2018; 44:371-391. [PMID: 30001781 DOI: 10.1016/j.rdc.2018.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.
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Affiliation(s)
- Blas Y Betancourt
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA.
| | - Ann Biehl
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, FDA, 10001 New Hampshire Avenue, Hillandale Building, 4th Floor Silver Spring, MD 20993, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
| | - Ananta Subedi
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
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Chaabane S, Messedi M, Akrout R, Ben Hamad M, Turki M, Marzouk S, Keskes L, Bahloul Z, Rebai A, Ayedi F, Maalej A. Association of hyperhomocysteinemia with genetic variants in key enzymes of homocysteine metabolism and methotrexate toxicity in rheumatoid arthritis patients. Inflamm Res 2018; 67:703-710. [PMID: 29796841 DOI: 10.1007/s00011-018-1161-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 05/10/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Souhir Chaabane
- Laboratory of Human Molecular Genetics, Faculty of Medicine, Avenue Majida Boulila, 3029, Sfax, Tunisia.
| | - Meriam Messedi
- UR "Molecular Bases of Human Diseases", Faculty of Medicine, Sfax, Tunisia
| | - Rim Akrout
- Department of Rheumatology, University Hospital Hedi Chaker, Sfax, Tunisia
| | - Mariem Ben Hamad
- Laboratory of Human Molecular Genetics, Faculty of Medicine, Avenue Majida Boulila, 3029, Sfax, Tunisia
| | - Mouna Turki
- UR "Molecular Bases of Human Diseases", Faculty of Medicine, Sfax, Tunisia
| | - Sameh Marzouk
- Department of Internal Medicine, University Hospital Hedi Chaker, Sfax, Tunisia
| | - Leila Keskes
- Laboratory of Human Molecular Genetics, Faculty of Medicine, Avenue Majida Boulila, 3029, Sfax, Tunisia
| | - Zouheir Bahloul
- Department of Internal Medicine, University Hospital Hedi Chaker, Sfax, Tunisia
| | - Ahmed Rebai
- Laboratory of Molecular and Cellular Screening Processes, Center of Biotechnology, Sfax, Tunisia
| | - Fatma Ayedi
- UR "Molecular Bases of Human Diseases", Faculty of Medicine, Sfax, Tunisia
| | - Abdellatif Maalej
- Laboratory of Human Molecular Genetics, Faculty of Medicine, Avenue Majida Boulila, 3029, Sfax, Tunisia
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Zhou YZ, Zhao LD, Chen H, Zhang Y, Wang DF, Huang LF, Lv QW, Liu B, Li Z, Wei W, Li H, Liao X, Liu H, Liu X, Jin H, Wang J, Fei YY, Wu QJ, Zhang W, Shi Q, Zheng WJ, Zhang FC, Tang FL, Lipsky PE, Zhang X. Comparison of the impact of Tripterygium wilfordii Hook F and Methotrexate treatment on radiological progression in active rheumatoid arthritis: 2-year follow up of a randomized, non-blinded, controlled study. Arthritis Res Ther 2018; 20:70. [PMID: 29636089 PMCID: PMC5894170 DOI: 10.1186/s13075-018-1563-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/12/2018] [Indexed: 01/19/2023] Open
Abstract
Background Tripterygium wilfordii Hook F (TwHF) alone or in combination with methotrexate (MTX) has been shown to be more effective than MTX monotherapy in controlling the manifestations in subjects with disease-modifying antirheumatic drug (DMARD)-naïve active rheumatoid arthritis (RA) over a 6-month period. The long-term impact of these therapies on disease activity and radiographic progression in RA has not been examined. Methods Patients with DMARD-naïve RA enrolled in the “Comparison of Tripterygium wilfordii Hook F with methotrexate in the Treatment of Active Rheumatoid Arthritis” (TRIFRA) study were randomly allocated into three arms with TwHF or MTX or the two in combination. Clinical indexes and radiographic data at baseline and year 2 was collected and compared using an intent-to-treat (ITT) and a per-protocol (PP) analysis. Two radiologists blinded to the treatment scored the images independently. Results Of 207 subjects 109 completed the 2-year follow up. The number of subjects withdrawing from the study and the number adhering to the initial regimens were similar among the three groups (p > = 0.05). In the ITT analysis, proportions of patients reaching American College of Rheumatology 50% (ACR50) response criteria were 46.4%, 58.0% and 50.7% in the MTX, TwHF and MTX + TwHF groups (TwHF vs MTX monotherapy, p = 0.004). Similar patterns were found in ACR20, ACR70, Clinical Disease Activity Index good responses, European League Against Rheumatism good response, remission rate and low disease activity rate at year 2. The results of the PP analysis agreed with those in the ITT analysis. The changes in total Sharp scores and joint erosion and joint space narrowing during the 2 years were associated with changes in disease activity measured by the 28-joint count Disease Activity Score and were comparable among the three groups (p > 0.05). Adverse events were similar in the three treatment groups. Conclusions During the 2-year therapy period, TwHF monotherapy was not inferior to MTX monotherapy in controlling disease activity and retarding radiological progression in patients with active RA. Trial registration This is a follow-up study. Original trial registration: ClinicalTrials.gov, NCT01613079. Registered on 4 June 2012.
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Affiliation(s)
- Yang-Zhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Li-Dan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Yan Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dan-Feng Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin-Fang Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China.,Department of Nephrology and Rheumatology, The First People's Hospital of ChenZhou, ChenZhou, Hunan, China
| | - Qian-Wen Lv
- The Body Sculpture and Liposuction Center of Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100144, China
| | - Bin Liu
- Department of Rheumatology, The Affiliated Hospital of QingDao University Medical College, Qingdao, Shandong, China
| | - Zhenbin Li
- Department of Rheumatology, The Bethune International Heping Hospital of Hebei, Shijiazhuang, Hebei, China
| | - Wei Wei
- Department of Rheumatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Hongbin Li
- Department of Rheumatology, Affiliated Hospital of Inner Mongolia Medical College, Hohhot, Inner Mongolia, China
| | - Xiangping Liao
- Department of Nephrology and Rheumatology, The First People's Hospital of ChenZhou, ChenZhou, Hunan, China
| | - Hui Liu
- Department of Rheumatology, Beijing Dongfang Hospital, Beijing, China
| | - Xiumei Liu
- Department of Rheumatology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongtao Jin
- Department of Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Junxiang Wang
- Department of Rheumatology, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yun-Yun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Qing-Jun Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Qun Shi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Wen-Jie Zheng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Feng-Chun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Fu-Lin Tang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Peter E Lipsky
- Formerly National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA. .,AMPEL BioSolutions, Charlottesville, VA, 22901, USA.
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China.
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58
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Yu MB, Firek A, Langridge WHR. Predicting methotrexate resistance in rheumatoid arthritis patients. Inflammopharmacology 2018. [DOI: 10.1007/s10787-018-0459-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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59
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Drug-Induced Gastrointestinal and Hepatic Disease Associated with Biologics and Nonbiologic Disease-Modifying Antirheumatic Drugs. Rheum Dis Clin North Am 2018; 44:29-43. [DOI: 10.1016/j.rdc.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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60
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Bronckers IMGJ, Seyger MMB, West DP, Lara-Corrales I, Tollefson M, Tom WL, Hogeling M, Belazarian L, Zachariae C, Mahé E, Siegfried E, Philipp S, Szalai Z, Vleugels RA, Holland K, Murphy R, Baselga E, Cordoro K, Lambert J, Alexopoulos A, Mrowietz U, Kievit W, Paller AS. Safety of Systemic Agents for the Treatment of Pediatric Psoriasis. JAMA Dermatol 2017; 153:1147-1157. [PMID: 28903160 DOI: 10.1001/jamadermatol.2017.3029] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Use of systemic therapies for moderate to severe psoriasis in children is increasing, but comparative data on their use and toxicities are limited. Objective To assess patterns of use and relative risks of systemic agents for moderate to severe psoriasis in children. Design, Setting, and Participants A retrospective review was conducted at 20 centers in North America and Europe, and included all consecutive children with moderate to severe psoriasis who used systemic medications or phototherapy for at least 3 months from December 1, 1990, to September 16, 2014. Main Outcomes and Measures The minimal core data set included age, sex, severity of psoriasis, systemic interventions, monitoring, adverse events (AEs), and reason for discontinuation. Results For 390 children (203 girls and 187 boys; mean [SD] age at diagnosis, 8.4 [3.7] years) with psoriasis who used 1 or more systemic medications, the mean interval between diagnosis and starting systemic therapy was 3.0 years. Methotrexate was used by 270 patients (69.2%), biologic agents (primarily etanercept) by 106 (27.2%), acitretin by 57 (14.6%), cyclosporine by 30 (7.7%), fumaric acid esters by 19 (4.9%), and more than 1 medication was used by 73 (18.7%). Of 270 children taking methotrexate, 130 (48.1%) reported 1 or more AEs associated with methotrexate, primarily gastrointestinal (67 [24.8%]). Folic acid 6 days per week (odds ratio, 0.16; 95% CI, 0.06-0.41; P < .001) or 7 days per week (OR, 0.21; 95% CI, 0.08-0.58; P = .003) protected against gastrointestinal AEs more than once-weekly folic acid, regardless of the total weekly dosage. Methotrexate-associated hepatic transaminase elevations were associated with obesity (35 of 270 patients [13.0%]), but a folic acid regimen was not. Injection site reactions occurred in 20 of 106 patients (18.9%) treated with tumor necrosis factor inhibitors, but did not lead to discontinuation of treatment. Having 1 or more AEs related to medication, gastrointestinal AE, laboratory abnormality, or AE leading to discontinuation of the drug was more likely with methotrexate than tumor necrosis factor inhibitors, but having 1 or more infections related to medication (predominantly upper airway) was less likely. Six patients developed a serious treatment-related AE (methotrexate, 3; fumaric acid esters, 2; and adalimumab, 1), but methotrexate and biologic agents were taken for a mean duration that was 2-fold greater than the mean duration for cyclosporine or fumaric acid esters. No patient developed tuberculosis or a malignant neoplasm. Conclusions and Relevance Medication-related AEs occur less often with tumor necrosis factor inhibitors than with methotrexate. Folic acid administration 6 or 7 times per week protected more against methotrexate-induced gastrointestinal AEs than did weekly administration. A prospective registry is needed to track the long-term risks of systemic agents for pediatric psoriasis.
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Affiliation(s)
| | - Marieke M B Seyger
- Department of Dermatology, Radboud University, Nijmegen, the Netherlands
| | - Dennis P West
- Department of Dermatology, Northwestern University, Chicago, Illinois.,Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Irene Lara-Corrales
- Department of Pediatric Medicine, Dermatology Section, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Megha Tollefson
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Wynnis L Tom
- Department of Dermatology, Rady Children's Hospital San Diego, University of California, San Diego.,Department of Pediatrics, Rady Children's Hospital San Diego, University of California, San Diego
| | - Marcia Hogeling
- Department of Dermatology, Phoenix Children's Hospital, Phoenix, Arizona.,now with the Department of Dermatology, University of California, Los Angeles
| | - Leah Belazarian
- Department of Dermatology, University of Massachusetts Medical School, Worcester
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Emmanuel Mahé
- Department of Dermatology, Hôpital Victor Dupouy Argenteuil, Argenteuil, France
| | - Elaine Siegfried
- Department of Dermatology, St Louis University School of Medicine, St Louis, Missouri.,Department of Pediatrics, St Louis University School of Medicine, St Louis, Missouri
| | - Sandra Philipp
- Psoriasis Research and Treatment Center, Charité-Universitäts-Medizin, Berlin, Germany
| | - Zsuzsanna Szalai
- Department of Dermatology, Heim Pál Children's Hospital, Budapest, Hungary
| | - Ruth Ann Vleugels
- Department of Dermatology, Boston Children's Hospital, Boston, Massachusetts
| | - Kristen Holland
- Department of Dermatology, Medical College of Wisconsin, Milwaukee.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Ruth Murphy
- Paediatric Dermatology Department, Nottingham University Hospitals, Nottingham, England
| | - Eulalia Baselga
- Department of Dermatology, Hospital de la Sanat Creu i Sant Pau, Barcelona, Spain
| | - Kelly Cordoro
- Department of Dermatology, University of California, San Francisco Medical Center, San Francisco.,Department of Pediatrics, University of California, San Francisco Medical Center, San Francisco
| | - Jo Lambert
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Alex Alexopoulos
- First Department of Pediatrics, Agia Sofia Children's Hospital, University of Athens Medical School, Athens, Greece
| | - Ulrich Mrowietz
- Psoriasis Center at the Department of Dermatology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Wietske Kievit
- Department for Health Evidence, Radboud University, Nijmegen, the Netherlands
| | - Amy S Paller
- Department of Dermatology, Northwestern University, Chicago, Illinois.,Department of Pediatrics, Northwestern University, Chicago, Illinois
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Leveraging the electronic health record to improve quality and safety in rheumatology. Rheumatol Int 2017; 37:1603-1610. [PMID: 28852846 DOI: 10.1007/s00296-017-3804-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/17/2017] [Indexed: 12/13/2022]
Abstract
During the last two decades, improving the quality and safety of healthcare has become a focus in rheumatology. Widespread use of electronic health records (EHRs) and the availability of digital data have the potential to drive quality improvement, improve patient outcomes, and prevent adverse events. In the coming years, developing and leveraging tools within the EHR will be the key to making the next big strides in improving the health of patients with rheumatoid arthritis and other rheumatic diseases, including building EHR infrastructure to capture patient outcomes and developing automated methods to retrieve information from free text of clinical notes.
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62
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Affiliation(s)
- Tom D Wilsdon
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
| | - Samuel L Whittle
- The Queen Elizabeth Hospital and University of Adelaide; Department of Rheumatology; 28 Woodville Road Woodville South Australia Australia 5011
| | - Tilenka RJ Thynne
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
| | - Arduino A Mangoni
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
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63
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Falvey S, Shipman L, Ilowite N, Beukelman T. Methotrexate-induced nausea in the treatment of juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2017; 15:52. [PMID: 28629458 PMCID: PMC5477111 DOI: 10.1186/s12969-017-0180-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methotrexate is the most commonly used disease modifying antirheumatic drug in the treatment of juvenile idiopathic arthritis and can be effective in controlling disease in many patients. MAIN BODY A significant proportion of patients experience nausea and vomiting induced by methotrexate therapy, which can lead to decreased quality of life and discontinuation of treatment with methotrexate. Many strategies have been employed in attempts to reduce methotrexate-induced nausea, including folate supplementation, switching from oral to subcutaneous methotrexate, anti-emetic therapy, behavioral therapy, and others. Anticipatory nausea can be difficult to treat, making primary prevention of nausea with anti-emetics an attractive approach. CONCLUSION Understanding the prevalence and impact of methotrexate-induced nausea, as well as potentially effective interventions, may help maximize the therapeutic benefits of methotrexate.
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Affiliation(s)
- Sonja Falvey
- 0000 0001 2169 2489grid.251313.7University of Mississippi School of Pharmacy, Oxford, USA
| | - Lauren Shipman
- 0000000106344187grid.265892.2Division of Pediatric Rheumatology, University of Alabama Birmingham, Birmingham, USA
| | - Norman Ilowite
- 0000 0001 2152 0791grid.240283.fChildren’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, USA
| | - Timothy Beukelman
- Division of Pediatric Rheumatology, University of Alabama Birmingham, Birmingham, USA.
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Krul L, Kremer BHA, Luijckx NBL, Leeman WR. Quantifiable risk–benefit assessment of micronutrients: From theory to practice. Crit Rev Food Sci Nutr 2017; 57:3729-3746. [DOI: 10.1080/10408398.2016.1162765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Lisette Krul
- Netherlands Organization for Applied Scientific Research TNO, Zeist, The Netherlands
| | - Bas H. A. Kremer
- Netherlands Organization for Applied Scientific Research TNO, Zeist, The Netherlands
| | | | - Winfried R. Leeman
- Netherlands Organization for Applied Scientific Research TNO, Zeist, The Netherlands
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65
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Tran-Minh ML, Sousa P, Maillet M, Allez M, Gornet JM. Hepatic complications induced by immunosuppressants and biologics in inflammatory bowel disease. World J Hepatol 2017; 9:613-626. [PMID: 28539989 PMCID: PMC5424291 DOI: 10.4254/wjh.v9.i13.613] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/01/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
The incidence of inflammatory bowel diseases (IBD) is rising worldwide. The therapeutic options for IBD are expanding, and the number of drugs with new targets will rapidly increase in coming years. A rapid step-up approach with close monitoring of intestinal inflammation is extensively used. The fear of side effects represents one the most limiting factor of their use. Despite a widespread use for years, drug induced liver injury (DILI) management remains a challenging situation with Azathioprine and Methotrexate. DILI seems less frequent with anti-tumor necrosis factor agents and new biologic therapies. The aim of this review is to report incidence, physiopathology and practical guidelines in case of DILI occurrence with the armamentarium of old and new drugs in the field of IBD.
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66
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Adly AS, Adly AS, Adly MS, Serry ZMH. Laser acupuncture versus reflexology therapy in elderly with rheumatoid arthritis. Lasers Med Sci 2017; 32:1097-1103. [PMID: 28451815 DOI: 10.1007/s10103-017-2213-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/19/2017] [Indexed: 12/16/2022]
Abstract
The purposes of this study are to determine and compare efficacy of laser acupuncture versus reflexology in elderly with rheumatoid arthritis. Thirty elderly patients with rheumatoid arthritis aged between 60 and 70 years were classified into two groups, 15 patients each. Group A received laser acupuncture therapy (904 nm, beam area of 1cm2, power 100 mW, power density 100 mW/cm2, energy dosage 4 J, energy density 4 J/cm2, irradiation time 40 s, and frequency 100,000 Hz). The acupuncture points that were exposed to laser radiation are LR3, ST25, ST36, SI3, SI4, LI4, LI11, SP6, SP9, GB25, GB34, and HT7. While group B received reflexology therapy, both offered 12 sessions over 4 weeks. The changes in RAQoL, HAQ, IL-6, MDA, ATP, and ROM at wrist and ankle joints were measured at the beginning and end of treatment. There was significant decrease in RAQoL, HAQ, IL-6, and MDA pre/posttreatment for both groups (p < 0.05); significant increase in ATP pre/posttreatment for both groups (p < 0.05); significant increase in ankle dorsi-flexion, plantar-flexion, wrist flexion, extension, and ulnar deviation ROM pre/posttreatment in group A (p < 0.05); and significant increase in ankle dorsi-flexion and ankle plantar-flexion ROM pre/posttreatment in group B (p < 0.05). Comparison between both groups showed a statistical significant decrease in MDA and a statistical significant increase in ATP in group A than group B. Percent of changes in MDA was 41.82%↓ in group A versus 21.68%↓ in group B; changes in ATP was 226.97%↑ in group A versus 67.02%↑ in group B. Moreover, there was a statistical significant increase in ankle dorsi-flexion, ankle plantar-flexion, wrist flexion, wrist extension, and radial deviation in group A than group B. Laser therapy is associated with significant improvement in MDA and ATP greater than reflexology. In addition, it is associated with significant improvement in ankle dorsi-flexion, ankle plantar-flexion, wrist flexion, wrist extension, and radial deviation greater than reflexology in elderly patients with rheumatoid arthritis.
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Affiliation(s)
- Afnan Sedky Adly
- Medical Applications of Laser in Physical Medicine, Physical Therapy for Cardiovascular-Respiratory Disorders and Geriatrics, Cairo University Kasr El Aini Medical School, Cairo, Egypt
| | - Aya Sedky Adly
- Computer Science, Biomedical Informatics, Helwan University Faculty of Computers and Information, Cairo, Egypt.
| | - Mahmoud Sedky Adly
- Orthodontics and Dentofacial Orthopedics, Medical Applications of Laser, Cairo University Faculty of Oral and Dental Medicine, Cairo, Egypt
| | - Zahra M H Serry
- Physical Therapy for Cardiovascular-Respiratory Disorders and Geriatrics, Cairo University Faculty of Physical Therapy, Cairo, Egypt
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Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol 2017; 9:67-79. [PMID: 28435338 PMCID: PMC5386601 DOI: 10.2147/oarrr.s131668] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be "rescued" by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed.
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Affiliation(s)
| | | | - Randy Jay
- Arizona Arthritis & Rheumatology Associates, Phoenix, AZ
| | - Petros Efthimiou
- Division of Rheumatology, New York Methodist Hospital, Brooklyn, NY, USA
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Schmajuk G, Tonner C, Miao Y, Yazdany J, Gannon J, Boscardin WJ, Daikh DI, Steinman MA. Folic Acid Supplementation Is Suboptimal in a National Cohort of Older Veterans Receiving Low Dose Oral Methotrexate. PLoS One 2016; 11:e0168369. [PMID: 27977768 PMCID: PMC5158188 DOI: 10.1371/journal.pone.0168369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/30/2016] [Indexed: 12/25/2022] Open
Abstract
Objectives Co-prescription of folic acid in patients receiving low dose oral methotrexate is recommended because it reduces adverse events and prolongs the use of methotrexate (MTX). However, little is known about how often new users of methotrexate are co-prescribed folic acid, and what factors are associated with its use. We aimed to determine the prevalence, predictors of, and persistence of folic acid use in a population-based cohort of MTX users with rheumatic diseases. Methods Using a national, administrative database of patients seen through the Veterans Health Administration (VHA) that included pharmacy and laboratory data, we performed an observational cohort study of veterans over 65 years old who were new users of MTX. We used log-binomial regression to identify independent predictors of folic acid use and Kaplan Meyer survival analysis to examine persistence of folic acid over time. Results We studied 2467 incident users of MTX. 27% of patients were not prescribed folic acid through the VHA pharmacy within 30 days of MTX initiation. Patients who did not see a rheumatologist were 23% less likely to receive folic acid compared to patients who did have a rheumatologist visit during the baseline period (RR (95% CI) 0.77 (0.72, 0.82). These results remained unchanged even after adjusting for demographic, clinical, and other factors (adjusted RR (95% CI) 0.78 (0.74, 0.85)). After 20 months, only 50% of patients continued to receive folic acid. Conclusions In a nationwide VHA cohort of new users of oral MTX, many patients did not receive folic acid or discontinued it over time. Rheumatologists were more likely to prescribe folic acid than other providers. These data highlight the need to improve patient safety for users of methotrexate by standardizing workflows for folic acid supplementation.
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Affiliation(s)
- Gabriela Schmajuk
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America.,Department of Medicine, Veterans Affairs Medical Center-San Francisco, San Francisco, CA, United States of America
| | - Chris Tonner
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Yinghui Miao
- Department of Medicine, Veterans Affairs Medical Center-San Francisco, San Francisco, CA, United States of America
| | - Jinoos Yazdany
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Jacqueline Gannon
- School of Public Health, Yale University, New Haven, CT, United States of America
| | - W John Boscardin
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - David I Daikh
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America.,Department of Medicine, Veterans Affairs Medical Center-San Francisco, San Francisco, CA, United States of America
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America.,Department of Medicine, Veterans Affairs Medical Center-San Francisco, San Francisco, CA, United States of America
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69
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Biehl AJ, Katz JD. Pharmacotherapy Pearls for the Geriatrician: Focus on Oral Disease-Modifying Antirheumatic Drugs Including Newer Agents. Clin Geriatr Med 2016; 33:1-15. [PMID: 27886691 DOI: 10.1016/j.cger.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Providing safe and effective pharmacotherapy to the geriatric patients with rheumatological disorders is an ongoing struggle for the rheumatologist and geriatrician alike. Cohesive communication and partnership can improve the care of these patients and subvert adverse outcomes. Disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the newest oral agent for treatment of rheumatoid arthritis, tofacitinib, have distinctive monitoring and adverse effect profiles. This article provides the general practitioner or geriatrician with clinically relevant pearls regarding the use of these interventions in older patients.
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Affiliation(s)
- Ann J Biehl
- Department of Pharmacy, National Institutes of Health Clinical Center, 10 Center Drive, Room 1C240, Bethesda, MD 20892-1196, USA.
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 6N-216F, Building 10, 9000 Rockville Pike, Bethesda, MD 20892, USA
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Coskun M, Steenholdt C, de Boer NK, Nielsen OH. Pharmacology and Optimization of Thiopurines and Methotrexate in Inflammatory Bowel Disease. Clin Pharmacokinet 2016; 55:257-74. [PMID: 26255287 DOI: 10.1007/s40262-015-0316-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Improving the efficacy and reducing the toxicity of thiopurines and methotrexate (MTX) have been areas of intense basic and clinical research. An increased knowledge on pharmacodynamics and pharmacokinetics of these immunomodulators has optimized treatment strategies in inflammatory bowel disease (IBD). This review focuses on the metabolism and mode of action of thiopurines and MTX, and provides an updated overview of individualized treatment strategies in which efficacy in IBD can be increased without compromising safety. The patient-based monitoring instruments adapted into clinical practice include pretreatment thiopurine S-methyltransferase testing, thiopurine metabolite monitoring, and blood count measurements that may help guiding the dosage to improve clinical outcome. Other approaches for optimizing thiopurine therapy in IBD include combination therapy with allopurinol, 5-aminosalicylates, and/or biologics. Similar strategies are yet to be proven effective in improving the outcome of MTX therapy. Important challenges for the management of IBD in the future relate to individualized dosing of immunomodulators for maximal efficacy with minimal risk of side effects. As low-cost conventional immunomodulators still remain a mainstay in pharmacotherapy of IBD, more research remains warranted, especially to substantiate these tailored management strategies in controlled clinical trials.
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Affiliation(s)
- Mehmet Coskun
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark. .,Department of Biology and Biotech Research and Innovation Centre (BRIC), The Bioinformatics Centre, University of Copenhagen, Copenhagen, Denmark.
| | - Casper Steenholdt
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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Hall JJ, Bolina M, Chatterley T, Jamali F. Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors. Ann Pharmacother 2016; 51:163-178. [DOI: 10.1177/1060028016672035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. Data Sources: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. Study Selection and Data Extraction: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. Data Synthesis: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. Conclusion: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.
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Curtis JR, Bykerk VP, Aassi M, Schiff M. Adherence and Persistence with Methotrexate in Rheumatoid Arthritis: A Systematic Review. J Rheumatol 2016; 43:1997-2009. [PMID: 27803341 DOI: 10.3899/jrheum.151212] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Medication adherence in patients with rheumatoid arthritis (RA) is typically suboptimal. Nonadherence has been associated with symptom worsening and increased disability. We systematically reviewed published clinical studies to evaluate methotrexate (MTX) adherence and persistence, factors associated with MTX adherence and persistence, and the effect of MTX nonadherence on clinical outcomes in RA. METHODS MEDLINE and Embase were systematically searched (inception to February 2016) using relevant keywords. Observational or interventional clinical studies in patients with RA that specifically reported adherence to or persistence with MTX were included. Data were extracted using a predesigned, standardized template that included study design, patient demographics, and relevant outcomes. Main outcomes were MTX adherence and persistence rates in patients with RA treated with MTX and factors associated with MTX adherence and persistence. RESULTS Of 365 references screened, 31 articles met inclusion criteria and another 10 were identified from searching reference lists. Estimates of MTX adherence varied from study to study because of heterogeneity in patient populations, duration of followup, definitions of adherence, and methods of assessment. Rates of MTX persistence ranged from 50% to 94% at 1 year and 25% to 79% at 5 years. No clear trends were identified in factors that influence MTX adherence and persistence. Two studies suggested that MTX adherence was associated with superior clinical outcomes. CONCLUSION MTX adherence and persistence are highly variable in patients with RA. Research is necessary to determine the effect of nonadherence on health outcomes and to identify independent predictors of nonadherence to inform evidence-based interventions.
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Affiliation(s)
- Jeffrey R Curtis
- From the Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; Inflammatory Arthritis Center, Hospital for Special Surgery, New York, New York; Rheumatology Division, University of Colorado School of Medicine, Greenwood Village, Colorado, USA; Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada; F. Hoffmann-La Roche Ltd., Basel, Switzerland. .,J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham; V.P. Bykerk, MD, Inflammatory Arthritis Center, Hospital for Special Surgery, and Department of Rheumatology, Mount Sinai Hospital; M. Aassi, MD, F. Hoffmann-La Roche Ltd.; M. Schiff, MD, Rheumatology Division, University of Colorado School of Medicine.
| | - Vivian P Bykerk
- From the Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; Inflammatory Arthritis Center, Hospital for Special Surgery, New York, New York; Rheumatology Division, University of Colorado School of Medicine, Greenwood Village, Colorado, USA; Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada; F. Hoffmann-La Roche Ltd., Basel, Switzerland.,J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham; V.P. Bykerk, MD, Inflammatory Arthritis Center, Hospital for Special Surgery, and Department of Rheumatology, Mount Sinai Hospital; M. Aassi, MD, F. Hoffmann-La Roche Ltd.; M. Schiff, MD, Rheumatology Division, University of Colorado School of Medicine
| | - Maher Aassi
- From the Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; Inflammatory Arthritis Center, Hospital for Special Surgery, New York, New York; Rheumatology Division, University of Colorado School of Medicine, Greenwood Village, Colorado, USA; Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada; F. Hoffmann-La Roche Ltd., Basel, Switzerland.,J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham; V.P. Bykerk, MD, Inflammatory Arthritis Center, Hospital for Special Surgery, and Department of Rheumatology, Mount Sinai Hospital; M. Aassi, MD, F. Hoffmann-La Roche Ltd.; M. Schiff, MD, Rheumatology Division, University of Colorado School of Medicine
| | - Michael Schiff
- From the Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; Inflammatory Arthritis Center, Hospital for Special Surgery, New York, New York; Rheumatology Division, University of Colorado School of Medicine, Greenwood Village, Colorado, USA; Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada; F. Hoffmann-La Roche Ltd., Basel, Switzerland.,J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham; V.P. Bykerk, MD, Inflammatory Arthritis Center, Hospital for Special Surgery, and Department of Rheumatology, Mount Sinai Hospital; M. Aassi, MD, F. Hoffmann-La Roche Ltd.; M. Schiff, MD, Rheumatology Division, University of Colorado School of Medicine
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Hart RI, McDonagh JE, Thompson B, Foster HE, Kay L, Myers A, Rapley T. Being as Normal as Possible: How Young People Ages 16-25 Years Evaluate the Risks and Benefits of Treatment for Inflammatory Arthritis. Arthritis Care Res (Hoboken) 2016; 68:1288-94. [PMID: 27040737 PMCID: PMC5042182 DOI: 10.1002/acr.22832] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 12/08/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore how young people (ages 16-25 years) with inflammatory arthritis evaluate the risks and benefits of treatment, particularly treatment with biologic therapies. METHODS This qualitative study involved in-depth interviews (n = 44) with young people, trusted others (e.g., parents), and health professionals; audio-recordings (n = 4) of biologic therapy-related consultations; and focus groups (n = 4). Analysis used techniques from grounded theory (open and focused coding, constant comparison, memoing, and mapping). RESULTS Young people aspired to live what they perceived as a "normal" life. They saw treatment as presenting both an opportunity for and a threat to achieving this. Treatment changes were therefore subject to complex and ongoing evaluation, covering administration, associated restrictions, anticipated effects, and side effects. Information sources included expert opinion (of professionals and other patients) and personal experience. Previous treatments provided important reference points. Faced with uncertain outcomes, young people made provisional decisions. Both trusted others and health professionals expressed concern that young people were too focused on short-term outcomes. CONCLUSION Young people value treatment that helps them to live a "normal" life. There is more to this than controlling disease. The emotional, social, and vocational consequences of treatment can be profound and lasting: opportunities to discuss the effects of treatment should be provided early and regularly. While making every effort to ensure understanding of the long-term clinical consequences of taking or not taking medication, the wider impact of treatment should not be dismissed. Only through understanding young people's values, preferences, and concerns can a sustainable balance between disease control and treatment burden be achieved.
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Affiliation(s)
| | | | - Ben Thompson
- Newcastle Hospitals NHS Foundation TrustNewcastle‐upon‐TyneUK
| | - Helen E. Foster
- Newcastle Hospitals NHS Foundation Trust and Newcastle UniversityNewcastle‐upon‐TyneUK
| | - Lesley Kay
- Newcastle Hospitals NHS Foundation TrustNewcastle‐upon‐TyneUK
| | - Andrea Myers
- Northumbria Healthcare NHS Foundation TrustNorth ShieldsUK
| | - Tim Rapley
- Newcastle UniversityNewcastle‐upon‐TyneUK
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Abstract
Low-dose methotrexate (MTX) therapy is a well-recognized therapy for many inflammatory conditions such as rheumatoid arthritis, psoriatic arthritis, and psoriasis. More than 20 years ago, the clinical efficacy of MTX was also established for steroid dependent Crohn's disease, but it was never broadly adapted as a treatment modality. More recently, MTX is being increasingly used in the pediatric population with Crohn's disease, both as a single agent as well as a concomitant therapy with anti-tumor necrosis factor-alpha treatment. This review outlines important pharmacological aspects for the therapeutic application of MTX and the current status of MTX as mono- or combination-therapy in both pediatric and adult patients with inflammatory bowel disease including new results of MTX monotherapy in steroid dependent ulcerative colitis.
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Targeting Immunomodulatory Agents to the Gut-Associated Lymphoid Tissue. NEURO-IMMUNO-GASTROENTEROLOGY 2016. [PMCID: PMC7123898 DOI: 10.1007/978-3-319-28609-9_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In addition to fluid haemostasis and lipid absorption, the lymphatic system and lymphoid tissues serve as the major host of immune cells where immune responses are evoked. Impaired function of the immune system might lead to serious diseases which are often treated by immunomodulators. This chapter briefly explores the physiology of an important part of the lymphatic system, the gut-associated lymphoid tissues (GALT). Currently used strategies for targeting GALT by immunomodulators for enhanced activity and/or decreased side effects are discussed. Strategies range from simple oral co-administration of immunomodulators with lipids to more advanced lipid-based formulations, polymer-based nanoparticle formulations and prodrugs. These targeting approaches successfully increase the concentration of immunomodulators achieved in the GALT and, more importantly, enhance immunomodulatory effects. Therefore, targeting immunomodulators to GALT represent a promising approach in the treatment of diseases where the immune system is actively involved.
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Romão VC, Lima A, Bernardes M, Canhão H, Fonseca JE. Three decades of low-dose methotrexate in rheumatoid arthritis: can we predict toxicity? Immunol Res 2015; 60:289-310. [PMID: 25391609 DOI: 10.1007/s12026-014-8564-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Methotrexate (MTX) is the anchor disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis (RA) treatment. It is used in monotherapy and/or in combination with other synthetic or biological DMARDs, and is known to have the best cost-effectiveness and efficacy/toxicity ratios. However, toxicity is still a concern, with a significant proportion of patients interrupting long-term treatment due to the occurrence of MTX-related adverse drug reactions (ADRs), which are the main cause of drug withdrawal. Despite the extensive accumulated experience in the last three decades, it is still impossible in routine clinical practice to identify patients prone to develop MTX toxicity. While clinical and biological variables, including folate supplementation, partially help to minimize MTX-related ADRs, the advent of pharmacogenomics could provide further insight into risk stratification and help to optimize drug monitoring and long-term retention. In this paper, we aimed to review and summarize current data on low-dose MTX-associated toxicity, its prevention and predictors, keeping in mind practical RA clinical care.
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Affiliation(s)
- Vasco C Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Edifício Egas Moniz, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
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Dhir V, Sandhu A, Kaur J, Pinto B, Kumar P, Kaur P, Gupta N, Sood A, Sharma A, Sharma S. Comparison of two different folic acid doses with methotrexate--a randomized controlled trial (FOLVARI Study). Arthritis Res Ther 2015; 17:156. [PMID: 26063325 PMCID: PMC4483203 DOI: 10.1186/s13075-015-0668-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction There is reasonable evidence that folic acid 5–10 mg per week leads to reduction in methotrexate (MTX) toxicity in rheumatoid arthritis (RA). However, this is based on studies conducted with lower MTX dosage than used currently. It is unclear whether higher doses of folic acid may be better in reducing toxicity. Methods This was a double-blind randomized controlled trial of 24 weeks duration. To be eligible, patients should have rheumatoid arthritis (1987 American College of Rheumatology criteria), be 18–75 years of age, not be on MTX and have active disease as defined by ‘Modified Disease Activity Score using three variables’ (DAS28(3)) > 3.2. MTX was started at 10 mg/week and escalated to 25 mg/week by 12 weeks. Folic acid was given at a dose of 10 mg (FA10) or 30 mg per week (FA30). Co-primary endpoints were incidence of toxicity (undesirable symptoms and laboratory abnormalities) and change in disease activity by 24 weeks. Intention-to-treat and per-protocol analyses were performed. Results Among 100 patients enrolled, 51 and 49 were randomized to FA10 and FA30 respectively. By 24 weeks, there were 6 patient withdrawals in either group and mean(±SD) dose of MTX was 22.8 ± 4.4 and 21.4 ± 4.6 mg per week (p = 0.1). Frequency of patients with undesirable symptoms was non-significantly lower by 7.4 % (95 % confidence interval −27.4 to 12.7 %) in FA10 compared to FA30. There was also no difference in frequency of transaminitis (>Upper limit of normal (ULN)) (42.6, 45.7 %, p = 0.7) or transminitis as per primary endpoint (>2xULN) (10.6, 8.7 %, p = 1.0) or cytopenias (4.3, 4.3 %, p = 0.9). There was no difference in the primary end-point of occurrence of any adverse effect (symptom or laboratory) in FA10 and FA30 (46.8, 54.3 %, p = 0.5). At 24 weeks, DAS28(3) declined in both groups by a similar extent (−1.1 ± 1.0, −1.3 ± 1.0, p = 0.2) and ‘European League Against Rheumatism’ good or moderate response occurred in 56.9 and 67.4 % (p = 0.3). Conclusions Even with the high doses of MTX used in current practice, there was no additional benefit (or harm) of a higher dose of folic acid (30 mg/week) over a usual dose (10 mg/week). Trial Registration Clinicaltrials.gov NCT01583959 Registered 15 March 2012
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Affiliation(s)
- Varun Dhir
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Amit Sandhu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Jasbinder Kaur
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India.
| | - Benzeeta Pinto
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Phani Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Prabhdeep Kaur
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Nidhi Gupta
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Ankita Sood
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Shefali Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
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A sandwich substrate for ultrasensitive and label-free SERS spectroscopic detection of folic acid / methotrexate. Biomed Microdevices 2015; 16:673-9. [PMID: 24850231 DOI: 10.1007/s10544-014-9871-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A highly sensitive surface enhanced Raman scattering (SERS) substrate with particle-film sandwich geometry has been developed for the label free detection of folic acid (FA) and methotrexate (MTX). In this sandwich structure, the bottom layer is composed of a copper foil decorated with silver nanoparticles synthesized by the galvanic displacement reaction, and top layer is constituted by silver nanoparticles. The FA and MTX molecules are sandwiched between the silver nanoparticles decorated copper film and the silver nanoparticles. The plasmonic coupling between the two layers of the sandwich structure greatly enhances the SERS spectra of FA and MTX. SERS activity of the substrate was studied and optimized by adjusting the time of galvanic displacement reaction. The SERS spectra of the FA and MTX showed the minimum detection concentration of 100 pM. The identification of methotrexate and folic acid analogs was also carried out by SERS spectra analysis.
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Ham AC, Enneman AW, van Dijk SC, Oliai Araghi S, Swart KMA, Sohl E, van Wijngaarden JP, van der Zwaluw NL, Brouwer-Brolsma EM, Dhonukshe-Rutten RAM, van Schoor NM, van der Cammen TJM, Zillikens MC, de Jonge R, Lips P, de Groot LCPGM, van Meurs JBJ, Uitterlinden AG, Witkamp RF, Stricker BHC, van der Velde N. Associations between medication use and homocysteine levels in an older population, and potential mediation by vitamin B12 and folate: data from the B-PROOF Study. Drugs Aging 2015; 31:611-21. [PMID: 24993981 DOI: 10.1007/s40266-014-0192-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Elevated homocysteine levels are a risk indicator for cardiovascular disease, fractures and cognitive decline. Previous studies indicated associations between homocysteine levels and medication use, including antihypertensive, lipid-lowering and antidiabetic medication. However, results were often contradictory and inconclusive. Our objective was to study the associations established previously in more detail by sub-classifying medication groups, and investigate the potential mediating role of vitamin B12 and folate status. MATERIALS AND METHODS Baseline data from the B-PROOF (B-vitamins for the PRevention Of Osteoporotic Fractures) study were used. We included 2,912 participants aged ≥65 years, with homocysteine levels of 12-50 μmol/L and creatinine levels ≤150 μmol/L, for whom self-reported medication data were available. We used multivariable linear regression models and analysis of covariance to assess the association between medication use and plasma homocysteine levels, and the potential mediation by serum vitamin B12 and folate. RESULTS The mean age was 74 years (standard deviation, 6.5), 50 % were women, and median homocysteine levels were 14 µmol/L [interquartile range, 13-17 µmol/L]. Higher mean homocysteine levels were observed in users vs. non-users for diuretics (15.2 vs. 14.9, p = 0.043), high-ceiling sulphonamide diuretics (16.0 vs. 14.9, p < 0.001), medication acting via the renin-angiotensin system (15.2 vs. 14.9, p = 0.029) and metformin (15.6 vs. 15.1, p = 0.006). Non-selective β-blocker use was associated with lower mean homocysteine levels (14.4 vs. 15.0, p = 0.019). Only this association was mediated by an underlying association with vitamin B12 and folate levels. CONCLUSION The associations between homocysteine levels and medication use appear to be fairly modest. Our results suggest that medication use is unlikely to contribute to clinically relevant changes in plasma homocysteine levels.
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Affiliation(s)
- Annelies C Ham
- Department of Internal Medicine, Erasmus MC, Geriatric Section, University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Pain reduction with oral methotrexate in knee osteoarthritis, a pragmatic phase iii trial of treatment effectiveness (PROMOTE): study protocol for a randomized controlled trial. Trials 2015; 16:77. [PMID: 25872649 PMCID: PMC4351849 DOI: 10.1186/s13063-015-0602-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/11/2015] [Indexed: 02/01/2023] Open
Abstract
Background Osteoarthritis (OA) is the fastest growing cause of disability worldwide. Current treatments for OA are severely limited and a large proportion of people with OA live in constant, debilitating pain. There is therefore an urgent need for novel treatments to reduce pain. Synovitis is highly prevalent in OA and is associated with pain. In inflammatory arthritides such as rheumatoid arthritis, methotrexate (MTX) is the gold standard treatment for synovitis and has a well-known, acceptable toxicity profile. We propose that using MTX to treat patients with symptomatic knee OA will be a practical and safe treatment to reduce synovitis and, consequently, pain. Methods/Design Pain Reduction with Oral Methotrexate in knee Osteoarthritis, a pragmatic phase III trial of Treatment Effectiveness (PROMOTE) is an investigator-initiated, multi-centre, randomized, double-blind, pragmatic placebo-controlled trial. A total of 160 participants with symptomatic knee OA will be recruited across primary and secondary care sites in the United Kingdom and randomized on a 1:1 basis to active treatment or placebo, in addition to usual care, for 12 months. As is usual practice for MTX, dosing will be escalated over six weeks to 25 mg (or maximum tolerated dose) weekly for the remainder of the study. The primary endpoint is change in average knee pain during the past week (measured on an 11-point numerical rating scale) between baseline and six months. Secondary endpoints include other self-reported pain, function and quality-of-life measures. A health economics analysis will also be performed. A magnetic resonance imaging substudy will be conducted to provide an explanatory mechanism for associated symptom change by examining whether MTX reduces synovitis and whether this is related to symptom change. Linear and logistic regression will be used to compare changes between groups using univariable and multivariable modelling analyses. All analyses will be conducted on an intention-to-treat basis. Discussion The PROMOTE trial is designed to examine whether MTX is an effective analgesic treatment for OA. The MRI substudy will address the relationship between synovitis and symptom change. This will potentially provide a much needed new treatment for knee OA. Trial registration Current Controlled Trials identifier: ISRCTN77854383 (registered: 25 October 2013).
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Goodman SM, Cronstein BN, Bykerk VP. Outcomes related to methotrexate dose and route of administration in patients with rheumatoid arthritis: a systematic literature review. Clin Exp Rheumatol 2015; 33:272-8. [PMID: 25536122 PMCID: PMC4406815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/05/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Methotrexate (MTX) is considered the 'anchor drug' in the therapy of rheumatoid arthritis (RA), yet many physicians do not optimise MTX regimens in spite of high RA disease activity. The recent development of an auto-injector for the subcutaneous (subQ) administration of MTX has prompted re-evaluation of MTX utilisation. The purpose of this systematic literature review is to determine the optimal dose, drug level, and route of administration for MTX in the context of relevant pharmacokinetics and pharmacogenomics. METHODS A systematic literature review was performed in Medline searching specifically for randomised controlled trials, systematic reviews, case control and cohort studies evaluating outcomes related to MTX dose and route of administration. Articles fulfilling these inclusion criteria were reviewed. Data on MTX dose, route of administration, clinical response, drug levels and adverse events were evaluated. RESULTS Our search identified 420 articles of which 6 were eligible for inclusion using the above criteria. These included 2 systematic reviews, 2 randomised open label trials, one longitudinal study and one retrospective cohort study. CONCLUSIONS Efficacy and toxicity for MTX appear related to absorbed dose of MTX, not to route of administration. While bioavailability is greater for parenteral MTX, there is no evidence yet that splitting the oral dose of MTX is less advantageous, less safe or less tolerable than administering parenteral MTX. However, there appear to be modest benefits in beginning with higher doses of MTX, and switching to parenteral MTX when the clinical response to an oral dose is inadequate.
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Affiliation(s)
- Susan M Goodman
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Bruce N Cronstein
- Departments of Medicine, Biochemistry and Molecular Pharmacology, and Pathology, NYU Langone Medical Center, New York, USA
| | - Vivian P Bykerk
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, USA
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Loza E, Lajas C, Andreu JL, Balsa A, González-Álvaro I, Illera O, Jover JÁ, Mateo I, Orte J, Rivera J, Rodríguez Heredia JM, Romero F, Martínez-López JA, Ortiz AM, Toledano E, Villaverde V, Carmona L, Castañeda S. Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis. Rheumatol Int 2014; 35:445-58. [PMID: 25543267 DOI: 10.1007/s00296-014-3196-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 12/17/2014] [Indexed: 12/19/2022]
Abstract
The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.
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Abstract
The antileukemic mechanisms of 6-mercaptopurine (6MP) and methotrexate (MTX) maintenance therapy are poorly understood, but the benefits of several years of myelosuppressive maintenance therapy for acute lymphoblastic leukemia are well proven. Currently, there is no international consensus on drug dosing. Because of significant interindividual and intraindividual variations in drug disposition and pharmacodynamics, vigorous dose adjustments are needed to obtain a target degree of myelosuppression. As the normal white blood cell counts vary by patients' ages and ethnicity, and also within age groups, identical white blood cell levels for 2 patients may not reflect the same treatment intensity. Measurements of intracellular levels of cytotoxic metabolites of 6MP and MTX can identify nonadherent patients, but therapeutic target levels remains to be established. A rise in serum aminotransferase levels during maintenance therapy is common and often related to high levels of methylated 6MP metabolites. However, except for episodes of hypoglycemia, serious liver dysfunction is rare, the risk of permanent liver damage is low, and aminotransferase levels usually normalize within a few weeks after discontinuation of therapy. 6MP and MTX dose increments should lead to either leukopenia or a rise in aminotransferases, and if neither is experienced, poor treatment adherence should be considered. The many genetic polymorphisms that determine 6MP and MTX disposition, efficacy, and toxicity have precluded implementation of pharmacogenomics into treatment, the sole exception being dramatic 6MP dose reductions in patients who are homozygous deficient for thiopurine methyltransferase, the enzyme that methylates 6MP and several of its metabolites. In conclusion, maintenance therapy is as important as the more intensive and toxic earlier treatment phases, and often more challenging. Ongoing research address the applicability of drug metabolite measurements for dose adjustments, extensive host genome profiling to understand diversity in treatment efficacy and toxicity, and alternative thiopurine dosing regimens to improve therapy for the individual patient.
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Lopez‐Olivo MA, Siddhanamatha HR, Shea B, Tugwell P, Wells GA, Suarez‐Almazor ME. Methotrexate for treating rheumatoid arthritis. Cochrane Database Syst Rev 2014; 2014:CD000957. [PMID: 24916606 PMCID: PMC7047041 DOI: 10.1002/14651858.cd000957.pub2] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Methotrexate is a folic acid antagonist widely used for the treatment of neoplastic disorders. Methotrexate inhibits the synthesis of deoxyribonucleic acid (DNA), ribonucleic acid (RNA) and proteins by binding to dihydrofolate reductase. Currently, methotrexate is among the most commonly used drugs for the treatment of rheumatoid arthritis (RA). This is an update of the previous Cochrane systematic review published in 1997. OBJECTIVES To evaluate short term benefits and harms of methotrexate for treating RA compared to placebo. SEARCH METHODS The Cochrane Musculoskeletal Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched from 1966 to 1997 and then updated to November 2013. The search was complemented with a bibliography search of the reference lists of trials retrieved from the electronic search. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials comparing methotrexate (MTX) monotherapy against placebo alone in people with RA. Any trial duration and MTX doses were included. DATA COLLECTION AND ANALYSIS Two review authors independently determined which studies were eligible for inclusion, extracted data and assessed risk of bias. Outcomes were pooled using mean differences (MDs) for continuous variables or standardized mean differences (SMDs) when different scales were used to measure the same outcome. Pooled risk ratio (RR) was used for dichotomous variables. Fixed-effect models were used throughout, although random-effects models were used for outcomes showing heterogeneity. MAIN RESULTS Five trials with 300 patients were included in the original version of the review. An additional two trials with 432 patients were added to the 2013 update of the review for a total of 732 participants. The trials were generally of unclear to low risk of bias with a follow-up duration ranging from 12 to 52 weeks. All trials included patients who have failed prior treatment (for example, gold therapy, D-penicillamine, azathioprine or anti-malarials); mean disease duration that ranged between 1 and 14 years with six trials reporting more than 4 years; and weekly doses that ranged between 5 mg and 25 mg. BENEFITS Statistically significant and clinically important differences were observed for most efficacy outcomes. MTX monotherapy showed a clinically important and statistically significant improvement in the American College of Rheumatology (ACR) 50 response rate when compared with placebo at 52 weeks (RR 3.0, 95% confidence interval (CI) 1.5 to 6.0; number needed to treat (NNT) 7, 95% CI 4 to 22). Fifteen more patients out of 100 had a major improvement in the ACR 50 outcome compared to placebo (absolute treatment benefit (ATB) 15%, 95% CI 8% to 23%).Statistically significant improvement in physical function (scale of 0 to 3) was also observed in patients receiving MTX alone compared with placebo at 12 to 52 weeks (MD -0.27, 95% CI -0.39 to -0.16; odds ratio (OR) 2.8, 95% CI 0.23 to 32.2; NNT 4, 95% CI 3 to 7). Nine more patients out of 100 improved in physical function compared to placebo (ATB -9%, 95% CI -13% to -5.3%). Similarly, the proportion of patients who improved at least 20% on the Short Form-36 (SF-36) physical component was higher in the MTX-treated group compared with placebo at 52 weeks (RR 1.5, 95% CI 1.0 to 2.1; NNT 9, 95% CI 4 to 539). Twelve more patients out of 100 showed an improvement of at least 20% in the physical component of the quality of life measure compared to placebo (ATB 12%, 95% CI 1% to 24%). No clinically important or statistically significant differences were observed in the SF-36 mental component.Although no statistically significant differences were observed in radiographic scores (that is, Total Sharp score, erosion score, joint space narrowing), radiographic progression rates (measured by an increase in erosion scores of more than 3 units on a scale ranging from 0 to 448) were statistically significantly lower for patients in the MTX group compared with placebo-treated patients (RR 0.31, 95% CI 0.11 to 0.86; NNT 13, 95% CI 10 to 60). Eight more patients out of 100 showed less damage to joints measured by an increase in erosion scores compared to placebo (ATB -8%, 95% CI -16% to -1%). In the one study measuring remission, no participants in either group met the remission criteria. These are defined by at least five of (≥ 2 months): morning stiffness of < 15 minutes, no fatigue, no joint pain by history, no joint tenderness, no joint swelling, and Westergren erythrocyte sedimentation rate (ESR) of < 20 mm/hr in men and < 30 mm/hr in women. HARMS Patients in the MTX monotherapy group were twice as likely to discontinue from the study due to adverse events compared to patients in the placebo group, at 12 to 52 weeks (16% versus 8%; RR 2.1, 95% CI 1.3 to 3.3; NNT 13, 95% CI 6 to 44). Compared to placebo, nine more people out of 100 who took MTX withdrew from the studies because of side effects (ATB 9%, 95% CI 3% to 14%). Total adverse event rates at 12 weeks were higher in the MTX monotherapy group compared to the placebo group (45% versus 15%; RR 3.0, 95% CI 1.4 to 6.4; NNT 4, 95% CI 2 to 17). Thirty more people out of 100 who took MTX compared to those who took placebo experienced any type of side effect (common or rare) (ATB 30, 95% CI 13% to 47%). No statistically significant differences were observed in the total number of serious adverse events between the MTX group and the placebo group at 27 to 52 weeks. Three people out of 100 who took MTX alone experienced rare but serious side effects compared to 2 people out of 100 who took a placebo (3% versus 2%, respectively). AUTHORS' CONCLUSIONS Based on mainly moderate to high quality evidence, methotrexate (weekly doses ranging between 5 mg and 25 mg) showed a substantial clinical and statistically significant benefit compared to placebo in the short term treatment (12 to 52 weeks) of people with RA, although its use was associated with a 16% discontinuation rate due to adverse events.
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Affiliation(s)
- Maria Angeles Lopez‐Olivo
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Harish R Siddhanamatha
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Beverley Shea
- University of OttawaDepartment of Epidemiology and Community Medicine501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaOntarioCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community Medicine501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Maria E Suarez‐Almazor
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
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Annussek T, Szuwart T, Kleinheinz J, Koiky C, Wermker K. In vitro inhibition of HUVECs by low dose methotrexate - insights into oral adverse events. Head Face Med 2014; 10:19. [PMID: 24884884 PMCID: PMC4033494 DOI: 10.1186/1746-160x-10-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/12/2014] [Indexed: 01/31/2023] Open
Abstract
Background With socio-economic changes, dentists and maxillofacial surgeons are more and more faced with medically compromised patients. Especially, the admission of antirheumatic drugs has increased remarkably. So dentists and maxillofacial surgeons should be aware of related adverse reactions that affect the craniofacial region. To identify possible cellular effects of disease modifying antirheumatic drugs (DMARDs) we investigated the influence of methotrexate (MTX) on human umbilical vein endothelial cells (HUVECs). Methods HUVECs were incubated with various concentrations of MTX, corresponding to serum concentrations found in rheumatoid arthritis (RA) patients. The effect of MTX on cell proliferation, differentiation as well as mitochondrial activity was measured by use of immunostaining, cell counting and 3-(4, 5-dimethylthiazol-2-yl)- 2, 5-diphenyltetrazolium bromide (MTT) assay. Results All samples incubated with MTX (1-1000 nM) showed significantly decreased cell viability when compared to controls. Cells were less proliferating, but did not lose their ability to synthesize endothelial proteins. A slight dose dependency of inhibiting effects was demonstrated. The observed differences between control and sample groups were rising with longer duration. Conclusion Because of the crucial role of endothelial cells and their precursor cells in wound healing, a negative influence of MTX on oral health has to be supposed, correlating to clinical observations of adverse reactions in the oral cavity, such as ulcerative or erosive lesions.
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Affiliation(s)
- Tobias Annussek
- Department of Cranio-Maxillofacial Surgery, University Hospital of Muenster, Research Group Vascular Biology of Oral Structures (VABOS), Waldeyerstr,30, Muenster 48149, Germany.
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Singh JA. Folic acid supplementation for rheumatoid arthritis patients on methotrexate: the good gets better. Cochrane Database Syst Rev 2013; 2013:ED000063. [PMID: 24151647 PMCID: PMC10846356 DOI: 10.1002/14651858.ed000063] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterMedicine ServiceBirminghamAL
- University of AlabamaDepartment of Medicine at School of Medicine, and Division of Epidemiology at School of Public HealthBirminghamAL
- Mayo Clinic College of MedicineDepartment of Orthopedic SurgeryRochesterMNUSA
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