Methotrexate toxicity during treatment of chronic plaque psoriasis: a case report and review of the literature

Efficacy of Leflunomide Compared to Methotrexate in the Treatment of Moderate to Severe Plaques Psoriasis: A Randomized Controlled Clinical Trial

INTRODUCTION

Psoriasis is a chronic inflammatory autoimmune skin disease. Several treatment options are available including topical and systemic options. Methotrexate was the main systemic medication in treating severe psoriasis, yet adverse events can limit its use. Leflunomide is an isoxazole derivative that inhibits the synthesis of pyrimidines, and subsequently inhibits RNA and DNA synthesis.

OBJECTIVES

As available data directly comparing MTX to leflunomide in psoriasis are lacking, this double blinded study was designed to compare the efficacy of methotrexate versus leflunomide in the treatment of moderate to severe psoriasis.

METHODS

The study included 40 patients (25 males and 15 females) with chronic plaque psoriasis. s. Patients were randomly assigned to one of two equal groups, group A for subcutaneous methotrexate injections and group B for leflunomide (loading dose 100mg daily for the first 3 days, then 20 mg daily for 3 months. Disease severity was determined by psoriasis area and severity index (PASI) score before and at the end of treatment The treatment response was evaluated at the baseline and weeks 4, 8 and 12 PASI score.

RESULTS

Both groups were matching at the baseline in aspects of gender, age, disease duration and PASI scores Both medications yielded comparable results with no significant difference between both groups in PASI score neither in side effects.

CONCLUSIONS

Leflunomide can be as effective as methotrexate in treatment of moderate to severe psoriasis.

Mucocutaneous Ulcers Unmasking Severe Systemic Methotrexate Toxicity - A Case-Series and Review of Literature

Background

Methotrexate is a widely used immunosuppressant with good efficacy and cost-effectiveness. However, one of the drawbacks of methotrexate has been toxicity due to accidental overdose. During the COVID pandemic, there was an alarming increase in the number of patients with methotrexate toxicity which prompted us to do this study.

Objective

To evaluate the clinical features and contributing factors in patients presenting with methotrexate toxicity.

Materials and Methods

A detailed evaluation of the clinical features, laboratory indices, contributing factors, and outcomes of the patients presenting with methotrexate toxicity was analyzed.

Results

A total of 19 cases were seen during the study period. All of the patients had oral mucositis and several developed cutaneous ulcerations. Laboratory abnormalities included cytopenia, transaminitis, and renal impairment. While sixteen patients recovered successfully, three people died as a result of delays in medical assistance. In addition to comorbidities, pandemic-induced restrictions played a major role in patients accidentally overdosing with methotrexate.

Conclusion

This study highlights the fact that even low-dose methotrexate taken incorrectly can result in a lethal outcome, which is preventable.

Secondary haemophagocytic lymphohistiocytosis vs methotrexate toxicity – a diagnostic conundrum

Summary

A 74-year-old female with a background of rheumatoid arthritis, managed with weekly methotrexate, was admitted with; oedema, dyspnoea, cachexia and jaundice. Bloods revealed pancytopenia, hyperferritinaemia, hyperbilirubinaemia, hypoalbuminaemia and hypofolataemia. Imaging showed a large right-sided pleural effusion, requiring therapeutic aspiration, and splenomegaly. Bone marrow aspirate revealed haemophagocytosis. Differential diagnoses included methotrexate toxicity (MTXT) and haemophagocytic lymphohistiocytosis (HLH). Management was initiated for MTXT whilst ongoing investigation for possible HLH continued.

Current status of therapeutic drug monitoring for methotrexate, imatinib, paclitaxel in China

BACKGROUND

Accurate TDMs of plasma methotrexate, imatinib and paclitaxel assist in the development of optimal therapeutic regimes. This study aims to investigate the current status of methotrexate, imatinib and paclitaxel measurements in China and explore the suitable EQA materials for those drugs.

METHODS

4 processed plasma samples including 2 levels of frozen pooled plasma samples and 2 levels of lyophilized pooled plasma samples were measured in different laboratories using different measurement systems. The inter-laboratory %CV and intra-measurement-system %CV of laboratories were calculated to assess the status of methotrexate, imatinib and paclitaxel measurements. The short-term stability and homogeneity of those processed samples were studied and compared. The relative differences (%) between the results of those two kinds of processed samples were also calculated to determine whether there were significant differences in their matrix effects for various measurement systems.

RESULTS

The mean inter-laboratory %CVs ranged from 12.8% to 15.3%, 14.7% to 19.6% and 56.8% to 81.6% for methotrexate, imatinib and paclitaxel, respectively. The intra-measurement %CV of homogeneous commercial measurement systems was better than other measurement systems. The lyophilized samples were more stable than frozen samples and there were no obvious differences in their matrix effects for most measurement systems.

CONCLUSIONS

The agreement among the results of methotrexate, imatinib, and especially paclitaxel from different laboratories was not satisfactory. Currently, the lyophilized samples were the more suitable EQA material for methotrexate, imatinib and paclitaxel than frozen samples.

Profile of Psoriasis Vulgaris Patients Treated with Methotrexate at Dr. Soetomo Hospital, Surabaya, 2017–2018

Background: Psoriasis Vulgaris is a chronic inflammatory skin disease that affects patients’ quality of life. Methotrexate is the first-line and most effective systemic therapy in psoriasis vulgaris management. Purpose: The aim of this study was to evaluate clinical improvement after methotrexate therapy and any adverse effects of methotrexate therapy in psoriasis vulgaris management. Methods: The data for this descriptive, retrospective study were retrieved from the medical records of 22 psoriasis vulgaris patients who were treated with methotrexate therapy between January 2017 and June 2018 in the Child Kemuning Ward (IRNA), Dr. Soetomo General Hospital in Surabaya, East Java. Results: Data for a total of 22 subjects were collected for this study. The majority of the subjects were in the age group 25–59, and the average age was 40.50±17.20. Good clinical improvement (decrease in the body surface area of the lesion) was found in all patients. The adverse effects of methotrexate were evaluated based on the elevation of liver and renal function test levels. An elevation of aspartate aminotransferase levels was found in 11 patients, and an elevation in alanine aminotransferase levels was found in 13 patients. Elevated blood urea nitrogen levels were found in eight patients, and elevated serum creatinine levels were found in four patients. Conclusion: Methotrexate is an effective treatment for severe psoriasis vulgaris management when administered with careful selection and regular monitoring of patients. Application of methotrexate therapy in accordance with the guidelines remains suitable for psoriasis vulgaris management with vigilance regarding methotrexate’s adverse effects.

Piperlongumine regulates epigenetic modulation and alleviates psoriasis-like skin inflammation via inhibition of hyperproliferation and inflammation

Psoriasis is an autoimmune skin disease, where chronic immune responses due to exaggerated cytokine signaling, abnormal differentiation, and evasion of keratinocytes apoptosis plays a crucial role in mediating abnormal keratinocytes hyperproliferation. From the therapeutic perspective, the molecules with strong anti-proliferative and anti-inflammatory properties could have tremendous relevance. In this study, we demonstrated that piperlongumine (PPL) treatment effectively abrogated the hyperproliferation and differentiation of keratinocytes by inducing ROS-mediated late apoptosis with loss of mitochondrial membrane potential. Besides, the arrest of cell cycle was found at Sub-G1 phase as a result of DNA fragmentation. Molecularly, inhibition of STAT3 and Akt signaling was observed with a decrease in proliferative markers such as PCNA, ki67, and Cyclin D1 along with anti-apoptotic Bcl-2 protein expression. Keratin 17 is a critical regulator of keratinocyte differentiation, and it was found to be downregulated with PPL significantly. Furthermore, prominent anti-inflammatory effects were observed by inhibition of lipopolysaccharide (LPS)/Imiquimod (IMQ)-induced p65 NF-κB signaling cascade and strongly inhibited the production of cytokine storm involved in psoriasis-like skin inflammation, thus led to the restoration of normal epidermal architecture with reduction of epidermal hyperplasia and splenomegaly. In addition, PPL epigenetically inhibited histone-modifying enzymes, which include histone deacetylases (HDACs) of class I (HDAC1-4) and class II (HDAC6) evaluated by immunoblotting and HDAC enzyme assay kit. In addition, our results show that PPL effectively inhibits the nuclear translocation of p65 and a histone modulator HDAC3, thus sequestered in the cytoplasm of macrophages. Furthermore, PPL effectively enhanced the protein-protein interactions of HDAC3 and p65 with IκBα, which was disrupted by LPS stimulation and were evaluated by Co-IP and molecular modeling. Collectively, our findings indicate that piperlongumine may serve as an anti-proliferative and anti-inflammatory agent and could serve as a potential therapeutic option in treating psoriasis.

Repurposing an old drug for new use: Niclosamide in psoriasis-like skin inflammation

Drug discovery is an onerous, extremely expensive, and time-consuming process. Instead, drug repurposing is an attractive strategy for exploiting novel indications for a drug beyond its original use. The untapped potential of drug repurposing compensates the barriers associated with the drug discovery pipeline. Psoriasis is an autoimmune skin disease, where hyperproliferation of keratinocytes and exaggerated immune responses are the important hallmarks of the disease. Extensive in vitro and preclinical research has demonstrated that niclosamide was found to exert potent anticancer and anti-inflammatory properties by targeting STAT3, p65 NF-κB, and NFATc-1 signaling paradigm with minimal host toxicity. From the disease perspective, the static intracellular molecular network in both cancer and psoriasis share overlapping pathological features in terms of hyperproliferation and chronic inflammation, which is mediated by the aforementioned signaling cascade. The plausible mechanistic relevance has prompted us to investigate the implementation of niclosamide for repositioning in psoriasis. Our in vitro and in vivo findings suggest that niclosamide inhibits keratinocytes hyperproliferation by reactive oxygen species-mediated apoptosis through the loss of mitochondrial membrane potential, cell cycle arrest at Sub G1 phase, and DNA fragmentation. Furthermore, niclosamide treatment resulted in abrogation of lipopolysaccharide-induced inflammatory cytokine levels in murine macrophages. Additionally, our results provided a preclinical rationale in imiquimod (IMQ)-induced BALB/c mouse model, where niclosamide diligently mitigated the IMQ-induced epidermal hyperplasia and inflammation by downregulating STAT3, p65 NF-κB, and NFATc-1 transcription factors along with Akt, Ki-67, and ICAM-1 protein expression.

Analytical methodologies for determination of methotrexate and its metabolites in pharmaceutical, biological and environmental samples

Methotrexate (MTX) is a folate antagonist drug used for several diseases, such as cancers, various malignancies, rheumatoid arthritis (RA) and inflammatory bowel disease. Due to its structural features, including the presence of two carboxylic acid groups and its low native fluorescence, there are some challenges to develop analytical methods for its determination. MTX is metabolized to 7-hydroxymethotrexate (7-OH-MTX), 2,4-diamino-N10-methylpteroic acid (DAMPA), and the active MTX polyglutamates (MTXPGs) in the liver, intestine, and red blood cells (RBCs), respectively. Additionally, the drug has a narrow therapeutic range; hence, its therapeutic drug monitoring (TDM) is necessary to regulate the pharmacokinetics of the drug and to decrease the risk of toxicity. Due to environmental toxicity of MTX; its sensitive, fast and low cost determination in workplace environments is of great interest. A large number of methodologies including high performance liquid chromatography equipped with UV-visible, fluorescence, or electrochemical detection, liquid chromatography-mass spectroscopy, capillary electrophoresis, UV-visible spectrophotometry, and electrochemical methods have been developed for the quantitation of MTX and its metabolites in pharmaceutical, biological, and environmental samples. This paper will attempt to review several published methodologies and the instrumental conditions, which have been applied to measure MTX and its metabolites within the last decade.

Low-dose methotrexate-induced vulvar edema: A case report

RATIONALE

Methotrexate (MTX) is an antimetabolite of folic acid, which is used for management of ectopic pregnancy. MTX-related toxicity may include cutaneous mucosal damage, bone marrow suppression, gastrointestinal disorders (gastritis, diarrhea, hematitis), liver and kidney function damage, pulmonary toxicity, cardiac toxicity, and nerve toxicity. However, it is not usual for vulvar edema induced by low-dose methotrexate.

PATIENT CONCERNS

In this case report, we described a patient with severe vulvar edema and oral cavity ulceration and scalp ulceration induced by low-dose MTX treatment for ectopic pregnancy. Her presenting complaints were pain in the vulva, oral cavity, and scalp.

DIAGNOSES

The patient was diagnosed based on clinical findings for MTX toxic reactions.

INTERVENTIONS

Vulva was disinfectioned with iodide and Kangfuxin solution, her mouth was rinsed with mouthwash. Three compound glycyrrhizin tablets were orally administered (3 times/day). After 10 days, the broken skin and mucous membrane healed.

OUTCOMES

The vulvar edema and oral cavity ulceration and scalp ulceration healed.

LESSONS

Our study demonstrated that even low-dose MTX can be induced skin and mucosal injury, patients and doctors should timely detection of drug toxicity reactions, immediately rescue, prompt discontinuation of medication, and symptomatic treatment to avoid accidental occurrence.

Benefit-risk profile of tofacitinib in patients with moderate-to-severe chronic plaque psoriasis: pooled analysis across six clinical trials

Background

Although existing psoriasis treatments are effective and well tolerated in many patients, there is still a need for new effective targeted treatment options. Tofacitinib is an oral Janus kinase inhibitor that has been investigated in patients with moderate‐to‐severe chronic plaque psoriasis.

Objectives

To consider the benefits and risks of tofacitinib in patients with moderate‐to‐severe psoriasis.

Methods

Data were pooled from one phase II, four phase III and one long‐term extension study comprising 5204 patient‐years of tofacitinib treatment. Efficacy end points included patients achieving Physician's Global Assessments of ‘clear’ or ‘almost clear’, ≥ 75% and ≥ 90% reduction in Psoriasis Area and Severity Index (coprimary end points) and improvements in Dermatology Life Quality Index score, Hospital Anxiety and Depression Scale depression score and Itch Severity Item score, at weeks 16 and 52. Safety data were summarized for 3 years of tofacitinib exposure.

Results

Tofacitinib 5 and 10 mg twice daily (BID) showed superiority over placebo for all efficacy end points at week 16, with response maintained for 52 weeks of continued treatment. Tofacitinib improved patients’ quality of life and was well tolerated. Rates of safety events of interest (except herpes zoster) were similar to those in the published literature and healthcare databases for other systemic psoriasis therapies. Tofacitinib 10 mg BID demonstrated greater efficacy than 5 mg BID.

Conclusions

Tofacitinib has a benefit–risk profile in moderate‐to‐severe psoriasis consistent with that of other systemic treatments.

What's already known about this topic?

Psoriasis is a chronic, systemic inflammatory disease, which has a significant impact on patients’ health‐related quality of life.

Although several existing psoriasis treatments are efficacious and well tolerated in many patients, some patients require treatment switching, and a proportion of patients remain untreated or undertreated.

Potential challenges to the use of existing therapies include safety issues and limited efficacy in some patients with conventional oral psoriasis treatments, inconvenience of topical treatments and the requirement for parenteral administration of biologics.

What does this study add?

Consistent efficacy and a safety profile consistent with that seen in rheumatoid arthritis, psoriatic arthritis and ulcerative colitis were demonstrated for oral tofacitinib in patients with moderate‐to‐severe psoriasis.

Tofacitinib has a benefit–risk profile in patients with moderate‐to‐severe psoriasis that is consistent with that of other systemic psoriasis treatments.

Linked Comment: Fleming. Br J Dermatol 2019; 180:13–14.

Plain language summary available online

Respond to this article

Methotrexate Cutaneous Toxicity following a Single Dose of 10 mg in a Case of Chronic Plaque Psoriasis: A Possible Idiosyncratic Reaction

Low-dose methotrexate is a well-tolerated and inexpensive systemic immunosuppressive agent used commonly in dermatology. However, several adverse events such as pancytopenia, pneumonitis, mucositis, and cutaneous ulcerations may develop during acute toxicity with dose-dependent or idiosyncratic mechanisms. Risk factors for methotrexate toxicity include advanced age, hypoalbuminemia, renal dysfunction, and concomitant drugs increasing the level of methotrexate in the body. We present a case of methotrexate toxicity presenting with classical features along with mucocutaneous side-effects, such as ulceration of psoriatic plaques and acral erythema, following a single dose of methotrexate.

Accidental Chronic Poisoning with Methotrexate; Report of Two Cases

Methotrexate has been used widely in dermatology, oncology and rheumatology fields. However, methotrexate-induced mucocutaneous lesions may occur in rare cases. In this case presentation, we report two cases of accidental poisoning with methotrexate. They had accidentally used methotrexate instead of digoxin. This case report emphasizes that early diagnosis and appropriate management is critical in order to improve outcome.

Effect of Nigella sativa (black seeds) against methotrexate-induced nephrotoxicity in mice

Aim:

To evaluate the protective effect of Nigella sativa (NS) against nephrotoxicity of methotrexate (MTX) in mice.

Materials and Methods:

Four groups of Swiss albino male mice, eight in each group were used. The study was carried on between October 2014 and April 2015. Group 1 (control) were administered 0.3 ml distilled water orally daily for 21 days and injected with normal saline (0.25 ml) IP weekly. Group 2 (MTX group) were treated with MTX, 10 mg/kg IP weekly, while Group 3 were treated with 0.125 ml of NS oil by mouth daily and injected with normal saline (0.25 ml) IP weekly. Group 4 received 0.125 ml of NS oil by mouth daily and injected with 10 mg/kg MTX IP weekly. Oral treatments were administered using a special curved smooth tip nontraumatic metal needle and IP injections were given for 3 weeks at days 7, 14 and 21. Animals were sacrificed at day 23. Malondialdehyde (MDA) and glutathione (GSH) measurements were performed on kidney homogenate. Histopathology of the kidneys were prepared and examined.

Results:

MTX has resulted in a small elevation in MDA and reduction in GSH levels in kidney homogenate which was returned back to control values when NS and MTX were administered in combination. Statistical significance was achieved with elevation of GSH by MTX and NS compared to MTX alone. MTX caused histopathological changes suggesting nephrotoxicity in 6 animals out of 8, while no changes were found in all animals treated with MTX and NS.

Conclusion:

NS is protective against MTX-induced nephrotoxicity.

Bioadhesive Surfactant Systems for Methotrexate Skin Delivery

Methotrexate (MTX) is an immunosuppressive drug for systemic use in the treatment of skin diseases, however, MTX presents a number of side effects, such as hepatotoxicity. To overcome this limitation, this study developed skin MTX delivery surfactant systems, such as a microemulsion (ME) and a liquid crystalline system (LCS), consisting of a glycol copolymer-based silicone fluid (SFGC) as oil phase, polyether functional siloxane (PFS) as surfactant, and carbomer homopolymer type A (C971) dispersion at 0.5% (wt/wt) as aqueous phase. Polarized light microscopy and small-angle X-ray scattering evidenced the presence of hexagonal and lamellar LCSs, and also a ME. Texture profile and in vitro bioadhesion assays showed that these formulations are suitable for topical application, showing interesting hardness, adhesiveness and compressibility values. Rheology analysis confirmed the Newtonian behaviour of the ME, whereas lamellar and hexagonal LCSs behave as pseudoplastic and dilatant non-Newtonian fluids, respectively. In vitro release profiles indicated that MTX could be released in a controlled manner from all the systems, and the Weibull model showed the highest adjusted coefficient of determination. Finally, the formulations were not cytotoxic to the immortalized human keratinocyte line HaCaT. Therefore, these bioadhesive surfactant systems established with PFS and C971 have great potential as skin delivery systems.

Methotrexate-induced nonhealing cutaneous ulcers in a nonpsoriatic patient without pancytopenia

Methotrexate forms one of the main drugs in the pharmacological management of rheumatoid arthritis, psoriasis, and some neoplastic diseases. Methotrexate rarely causes cutaneous ulceration and most cases are reported in patients with psoriasis and have been accompanied by pancytopenia. The author here reports occurrence of multiple (two) cutaneous ulcers due to methotrexate in a nonpsoriatic patient. The patient was on methotrexate for seronegative rheumatoid arthritis for 10 years. To the best of the Author's knowledge, this is a rare case of cutaneous ulceration due to methotrexate in a nonpsoriatic patient reported in the literature so far, and probably one of its kind without pancytopenia or other hematological abnormalities. Stopping this medication led to complete healing of the ulcerated lesion in about four to six weeks.