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Quan Soon KL, Shah S, Ibrahim R, Alzwahereh K. A Case Report on Iatrogenic Methotrexate Toxicity. Cureus 2024; 16:e64081. [PMID: 39114248 PMCID: PMC11305145 DOI: 10.7759/cureus.64081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
This case study studies the adverse effects of methotrexate toxicity as well as the importance of early recognition of the symptoms and signs of methotrexate toxicity. This study involves a 54-year-old female who accidentally took methotrexate in high doses for a period of five consecutively days. The patient had been diagnosed with mixed connective tissue disease and was being treated with methotrexate once weekly. However, she took 7.5 mg (three tablets) three times a day for five days instead of 15 mg once weekly in two divided doses. The patient immediately went to the ER but was asymptomatic and discharged after a CBC showed values within the normal range. The patient was then seen by her primary care physician and advised to return to the ER. At this time, the patient had mucocutaneous lesions and was complaining of oral and throat pain, and a repeat CBC demonstrated pancytopenia. The patient was admitted to the hospital for further management and treatment of methotrexate toxicity.
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Affiliation(s)
| | - Sundeep Shah
- Internal Medicine, Premier Medical Associates, The Villages, USA
| | - Ramy Ibrahim
- Research, Premier Medical Associates, The Villages, USA
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2
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Chan BS, Bosco AA, Buckley NA. Navigating methotrexate toxicity: Examining the therapeutic roles of folinic acid and glucarpidase. Br J Clin Pharmacol 2024. [PMID: 38889902 DOI: 10.1111/bcp.16096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 06/20/2024] Open
Abstract
Methotrexate (MTX) toxicity varies depending on factors such as dosing frequency (acute or repeated), dosage (low or high) and the administration route (oral, parenteral or intrathecal). Renal impairment can trigger or exacerbate MTX toxicity. Acute oral low-dose MTX (LDMTX) overdoses seldom lead to toxicity due to the saturable maximal bioavailable dose, but toxicity risks increase with repeated low doses (>3 days), high-dose MTX (HDMTX) or intrathecal poisoning. Folinic acid shares MTX transporters in the gut and cells and bypasses the MTX-induced dihydrofolate reductase inhibition. The required folinic acid dosage differs for low-dose and high-dose MTX toxicities. Acute LDMTX poisoning rarely requires folinic acid, while chronic LDMTX poisoning needs low-dose folinic acid until cellular function is restored. In HDMTX toxicities, early intravenous folinic acid administration is recommended, with dose and duration being guided by MTX concentrations and clinical improvement. In intrathecal MTX poisoning, folinic acid should be administered intravenously. Glucarpidase, a recombinant bacterial enzyme, has a high affinity for MTX and folate analogues in the intravascular or intrathecal systems. It decreases serum MTX concentrations by 90%-95% within 15 min. Its primary indication is for intrathecal MTX poisoning. It is rarely indicated in HDMTX toxicity unless patients have renal injury. However, there is no literature evidence supporting its use in HDMTX poisoning. Its use is limited by its significant cost and lack of availability. Haemodialysis can be potentially useful for MTX removal in cases where glucarpidase is not available. Additionally, fluid hydration, renal support and urine alkalinization are important adjunctive therapies for managing MTX toxicities.
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Affiliation(s)
- Betty S Chan
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Annmarie A Bosco
- Haematology Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Nicholas A Buckley
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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3
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Jain S, Pyle HJ, Evans JC, Gao W, Mauskar MM. Cutaneous manifestations of systemic methotrexate toxicity. JAAD Int 2024; 15:179-181. [PMID: 38651037 PMCID: PMC11033189 DOI: 10.1016/j.jdin.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Affiliation(s)
- Shivani Jain
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hunter J. Pyle
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica C. Evans
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Whitney Gao
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melissa M. Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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Gertel S, Rokach M, Polachek A, Litinsky I, Anouk M, Elkayam O, Furer V. Anti-inflammatory effects of infliximab and methotrexate on peripheral blood and synovial fluid mononuclear cells: ex vivo study. Scand J Rheumatol 2024; 53:188-198. [PMID: 38275170 DOI: 10.1080/03009742.2023.2300887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE To investigate the effects of methotrexate (MTX) and the tumour necrosis factor inhibitor infliximab (IFX) on immune cells derived from peripheral blood mononuclear cells (PBMCs) and synovial fluid mononuclear cells (SFMCs) of inflammatory arthritis patients. METHOD Phytohaemagglutinin (PHA)-induced proliferation of healthy donors' PBMCs and synovial intermediate monocytes (CD14+CD16+ cells) in SFMCs derived from psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients was determined by flow cytometry following co-culture with IFX and MTX. PHA-induced interferon-γ (IFN-γ) production in PBMCs was measured by enzyme-linked immunosorbent assay. The drugs' effect on mRNA expression in SFMCs was determined by quantitative polymerase chain reaction. RESULTS The combination of IFX 10 μg/mL + MTX 0.1 μg/mL had the strongest inhibitory effect on PBMC proliferation (91%), followed by MTX 0.1 μg/mL (86%) and IFX 10 μg/mL (49%). In PHA-stimulated PBMCs, IFN-γ production was reduced by IFX 10 μg/mL, MTX 0.1 μg/mL, and IFX 10 μg/mL + MTX 0.1 μg/mL by 68%, 90%, and 85%, respectively. In SFMCs, IFX 10 µg/mL significantly reduced CD14+CD16+ cells compared to medium (PsA 54%, p < 0.01; RA 46%, p < 0.05), while MTX had no effect on this population. IFX + MTX led to a similar suppression of CD14+CD16+ cells as achieved by IFX alone. The drugs had different impacts on SFMC gene expression. CONCLUSION Both IFX and MTX effectively inhibited PBMC proliferation and IFN-γ production, but only IFX reduced synovial monocytes and pro-inflammatory gene expression in SFMCs, suggesting a differential impact of IFX and MTX on critical inflammatory cell populations ex vivo.
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Affiliation(s)
- S Gertel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Rokach
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Polachek
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Litinsky
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Anouk
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Janet JV, Bhat PI, Prathibha J, Augustine M, Madhukara J. Mucocutaneous Ulcers Unmasking Severe Systemic Methotrexate Toxicity - A Case-Series and Review of Literature. Indian Dermatol Online J 2024; 15:473-479. [PMID: 38845636 PMCID: PMC11152471 DOI: 10.4103/idoj.idoj_567_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/09/2023] [Accepted: 11/06/2023] [Indexed: 06/09/2024] Open
Abstract
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.
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Affiliation(s)
- J Vincy Janet
- Department of Dermatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Pernaje Ishwara Bhat
- Department of Dermatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
| | - J.P. Prathibha
- Department of Dermatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Mary Augustine
- Department of Dermatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
| | - J. Madhukara
- Department of Dermatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
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Özhan AK, Demirhan A, Arikoglu T, Karahan F, Satıcı FEG, Tokmeci N, Gündoğan BD, Yalaki Aİ, Akbey V, Karabulut YY, Ünal S, Kuyucu S. Toxic Skin Reactions Should Be Differentiated from Allergic Reactions to Chemotherapeutic Drugs in Children: A Case Series and Review of the Literature. Dermatitis 2024; 35:275-287. [PMID: 38165639 DOI: 10.1089/derm.2023.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Background: Chemotherapeutic drugs can lead to a wide spectrum of cutaneous findings, ranging from nonimmune toxic reactions to severe immune-mediated hypersensitivity reactions. The aim of this study was to evaluate the clinical, histopathological features, and prognosis of toxic skin reactions to chemotherapeutic drugs and to compare them with characteristics of immune-mediated reactions in children with malignancies. Methods: The medical records of all children with cancer who experienced skin reactions after chemotherapy administration and diagnosed as a toxic skin reaction between 2010 and 2022 were retrospectively analyzed. The diagnosis was re-evaluated and differentiated from other similar disorders by using clinical manifestations, photodocumentation, and histopathological findings. Results: A total of 17 children aged 2-17 years were involved: toxic erythema of chemotherapy (TEC) in 14 children, methotrexate-induced epidermal necrosis in 2 children, and toxic epidermal necrolysis (TEN)-like TEC in 1 child. The most commonly implicated drug was methotrexate. Most patients recovered rapidly after drug cessation and supportive measures. In 10 of the 17 patients, reintroduction of the culprit chemotherapeutic drug at reduced doses or increased dosage intervals was possible without any recurrence. Six patients could not receive further doses since they deceased due to sepsis and other complications. Conclusions: Cutaneous toxic eruptions to chemotherapeutic drugs may present with a severe phenotype resembling Stevens-Johnson syndrome/TEN. An accurate diagnosis prevents potentially harmful therapeutic interventions, withholding of chemotherapy, and erroneous assignment of drug allergies.
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Affiliation(s)
- Aylin Kont Özhan
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Tuğba Arikoglu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Feryal Karahan
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | | | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Begümhan Demir Gündoğan
- Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Aysu İlhan Yalaki
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Veysi Akbey
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | | | - Selma Ünal
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Landau M, Silikovich F, Fida M, Cartier H, Kroumpouzos G. Oral Methotrexate Treatment of Delayed-Onset Inflammatory Reactions to Dermal Fillers. Aesthet Surg J Open Forum 2024; 6:ojae011. [PMID: 38690015 PMCID: PMC11060488 DOI: 10.1093/asjof/ojae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background In aesthetic practice, delayed-onset (late) inflammatory reactions (DIRs) to dermal fillers are encountered. The treatment of DIRs can be challenging, with a response to established therapies, including oral antibiotics, intralesional and oral steroids, and hyaluronidase injection, occasionally reported as unsatisfactory. Objectives Evaluate the efficacy of low-dose oral methotrexate (MTX) therapy in treating recalcitrant DIRs. Methods We retrospectively reviewed cases of recalcitrant DIRs treated with oral MTX. Data collected included individuals' gender and age, medical history, filler type, facial area(s) injected, previous treatments attempted to dissolve the DIR, MTX treatment dosage and duration, and outcome. Adverse events were monitored throughout the treatment. Results Thirteen females with a mean age of 52.6 years (range, 31-67 years) who developed recalcitrant DIRs to dermal filler injection are included. Eight reactions were triggered by the injection of hyaluronic acid (HA) fillers, 4 by liquid injectable silicone (LIS), and 1 by polymethylmethacrylate (PMMA). The average starting dosage of MTX was 12.1 mg/week (range, 7.5-12.5 mg/week). Patients were treated for 2 to 3 months in most cases. The average follow-up post-MTX therapy was 11.8 months (range, 2-36 months). A complete response to MTX treatment was observed in 10 patients (6 HA and 4 LIS cases), partial response in 1 (HA case), and an unsatisfactory response in 2 (HA and PMMA cases). Treatment was well tolerated. Conclusions A short course of low-dose oral MTX is a possible treatment for DIRs that have not responded to established therapies. The promising results of this report require validation by powered studies. Level of Evidence 4
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Affiliation(s)
| | | | | | | | - George Kroumpouzos
- Corresponding Author: Dr George Kroumpouzos, 541 Main St, Suite 320, South Weymouth, MA 02190, USA. E-mail:
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Hosseini E, Shahbazi F. Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature. Curr Drug Saf 2024; 19:224-235. [PMID: 37194235 DOI: 10.2174/1574886318666230516115737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/15/2023] [Accepted: 04/03/2023] [Indexed: 05/18/2023]
Abstract
Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.
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Affiliation(s)
- Elham Hosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Musameh I, Al-Bakri F, Ezzeldin A. Low serum level and chronic toxicity for methotrexate. Case Report. Qatar Med J 2023; 2023:31. [PMID: 38026729 PMCID: PMC10644175 DOI: 10.5339/qmj.2023.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Methotrexate (MTX) is a folic acid antagonist used to treat different immunological or proliferative illnesses because of its anti-proliferative and anti-inflammatory effects. MTX Toxicity is considered a severe problem. Although acute toxicity related to high-dose administration (doses ≥500 mg/m2) can be predicted based on the given dose, chronic toxicity still has no specific factors to predict it, so treatment depends on the history and symptoms of toxicity. MTX was initially used for oncology indications with high cyclic doses, then expanded to non-oncology indications with different low doses and frequencies. This significant change in doses resulted in dosing errors that contributed to MTX toxicity reports. Measures to prevent the toxicity of MTX should be implemented. CASE A 66-year-old female patient ingested 10 mg of MTX daily for one month instead of the once-toxicity symptoms. The serum level of MTX was requested, and treatment with folinic acid was initiated until the patient improved with the discontinuation of MTX. DISCUSSION There is limited literature about the lack the total cumulative dose, duration of intake, or serum level of MTX. All this information was provided in this case report, but drug-drug interactions were not reviewed, although aspirin and pantoprazole were identified as having interactions with methotrexate in this patient. Minimum total cumulative dose identification may help assess the toxicity risk in such patients. CONCLUSION Low-dose MTX chronic toxicity still needs further information to guide the patient's risk of toxicity and when to initiate treatment. Safety-practical measures should be implemented to prevent such administration errors.
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Affiliation(s)
| | - Faten Al-Bakri
- Emergency Department, Hamad General Hospital, Qatar E-mail:
| | - Asmaa Ezzeldin
- Clinical Pharmacy Service, Hamad General Hospital, Qatar
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Slavick A, Furer V, Polachek A, Tzemach R, Elkayam O, Gertel S. Circulating and Synovial Monocytes in Arthritis and Ex-Vivo Model to Evaluate Therapeutic Modulation of Synovial Monocytes. Immunol Invest 2023; 52:832-855. [PMID: 37615125 DOI: 10.1080/08820139.2023.2247438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Monocytes are innate immune cells that play a dual role in protection of host against pathogens and initiation and perpetuation of inflammatory disorders including joint diseases. During inflammation, monocytes migrate from peripheral blood to tissues via chemokine receptors where they produce inflammatory factors. Monocytes are classified into three subsets, namely: classical, intermediate and non-classical, each subset has particular function. Synovium of patients with inflammatory joint diseases, such as rheumatoid arthritis and psoriatic arthritis as well as osteoarthritis, is enriched by monocytes that differ from circulatory ones by distinct subsets distribution. Several therapeutic agents used systemically or locally through intra-articular injections in arthritis management modulate monocyte subsets. This scoping review summarized the existing literature delineating the effect of common therapeutic agents used in arthritis management on circulating and synovial monocytes/macrophages. As certain agents have an inhibitory effect on monocytes, we propose to test their potential to inhibit synovial monocytes via an ex-vivo platform based on cultured synovial fluid mononuclear cells derived from patients with rheumatic diseases. Information obtained from the ex-vivo platform can be applied to explore the therapeutic potential of medications in clinical practice.
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Affiliation(s)
- Adam Slavick
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Polachek
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reut Tzemach
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Smadar Gertel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kaikati J, Jabbour R, Khater JA, Skaff S, Tomb R. An unusual presentation of acute methotrexate-induced skin toxicity. Ann Dermatol Venereol 2023; 150:134-136. [PMID: 36641375 DOI: 10.1016/j.annder.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/25/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Affiliation(s)
- J Kaikati
- Dermatology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
| | - Rita Jabbour
- Dermatology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Jad Abou Khater
- Dermatology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Stephanie Skaff
- Dermatology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Roland Tomb
- Dermatology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
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Khan A, Anwar M, Azam A, Nisar S, Rehman AU. Hypoplastic Myelodysplastic Syndrome: Symptom of Methotrexate Toxicity in Rheumatoid Arthritis. Cureus 2023; 15:e40580. [PMID: 37469807 PMCID: PMC10352143 DOI: 10.7759/cureus.40580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2023] [Indexed: 07/21/2023] Open
Abstract
Methotrexate is the conventional disease-modifying anti-rheumatic drug (DMARD) which is considered the drug of choice in the treatment of rheumatoid arthritis, but its prolonged use without monitoring leads to a number of complications involving different body systems. The toxic effects of long-term methotrexate (MTX) therapy mainly involve the liver, skin, gastrointestinal tract (GIT) and bone marrow. In the bone marrow, it mainly causes suppression of normal functionality, leading to the formation of abnormal blast cells and dysplasia. In this case report, we present a male patient with symptoms of hoarseness, fatigue and abnormal bleeding all of which can be affiliated with methotrexate-induced hypoplastic myelodysplasia. As pancytopenia can be a lethal complication of MTX toxicity, it is important to monitor the therapy and dosage of methotrexate so that in case of any unforeseen development of a complication vital steps may be taken to diagnose and treat it in time. Regarding our patient, after thorough history taking and undergoing extensive hematological workup, the diagnosis of MTX-induced hypoplastic myelodysplasia was made. His symptoms improved on withholding the drug methotrexate from his active regimen and adding folinic acid and colony-stimulating factors.
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Affiliation(s)
- Adil Khan
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Maryem Anwar
- Family Medicine, NHS (National Health Service), Slough, GBR
| | - Adila Azam
- Paediatrics, Leeds Teaching Hospitals NHS (National Health Service) Trust, Leeds, GBR
| | - Sarah Nisar
- Internal Medicine, Khyber Medical College, Peshawar, PAK
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Shi T, Liu K, Peng Y, Dai W, Du D, Li X, Liu T, Song N, Meng Y. Research progress on the therapeutic effects of nanoparticles loaded with drugs against atherosclerosis. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07461-0. [PMID: 37178241 DOI: 10.1007/s10557-023-07461-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
Presently, there are many drugs for the treatment of atherosclerosis (AS), among which lipid-lowering, anti-inflammatory, and antiproliferative drugs have been the most studied. These drugs have been shown to have inhibitory effects on the development of AS. Nanoparticles are suitable for AS treatment research due to their fine-tunable and modifiable properties. Compared with drug monotherapy, experimental results have proven that the effects of nanoparticle-encapsulated drugs are significantly enhanced. In addition to nanoparticles containing a single drug, there have been many studies on collaborative drug treatment, collaborative physical treatment (ultrasound, near-infrared lasers, and external magnetic field), and the integration of diagnosis and treatment. This review provides an introduction to the therapeutic effects of nanoparticles loaded with drugs to treat AS and summarizes their advantages, including increased targeting ability, sustained drug release, improved bioavailability, reduced toxicity, and inhibition of plaque and vascular stenosis.
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Affiliation(s)
- Tianfeng Shi
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
- Department of Physiology, College of Basic Medicine, Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Kunkun Liu
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
- Department of Physiology, College of Basic Medicine, Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Yueyou Peng
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
| | - Weibin Dai
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
| | - Donglian Du
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
| | - Xiaoqiong Li
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
| | - Tingting Liu
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
- Medical Imaging Department of Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Ningning Song
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China
- Medical Imaging Department of Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Yanfeng Meng
- Department of Radiology, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, 030009, Shanxi, China.
- Department of Physiology, College of Basic Medicine, Shanxi Medical University, Taiyuan, 030001, Shanxi, China.
- Medical Imaging Department of Shanxi Medical University, Taiyuan, 030001, Shanxi, China.
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14
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Jafari F, Arasteh O, Hosseinjani H, Allahyari A, Ataei Azimi S, Askari VR. A critical review of methotrexate clinical interactions: role of transporters. Expert Opin Drug Metab Toxicol 2023; 19:91-107. [PMID: 36946211 DOI: 10.1080/17425255.2023.2193325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Methotrexate (MTX) is an anti-folate and immunosuppressive drug prescribed for various malignancies and immune diseases. However, delayed elimination of MTX associated with concomitant use of some medications can lead to severe and life-threatening adverse effects. AREAS COVERED This paper investigated drug-MTX interactions that lead to elevated MTX levels and related adverse effects due to the role of transporters. Methotrexate toxicity occurs at both low and high doses administrations. According to the studies we reviewed in this paper, most interaction records with methotrexate occurred with co-administration of indomethacin, ketoprofen, omeprazole, piperacillin/tazobactam, ciprofloxacin, co-trimoxazole, probenecid, and imatinib, mainly due to the role of transporters. However, most studies were performed as case reports or series, and confirming the exact drug-methotrexate interaction still needs further clinical investigations. EXPERT OPINION Our findings showed no firm evidence of interactions of proton pump inhibitors (PPIs), levetiracetam, and NSAIDS with MTX. Moreover, patients' risk factors, hypoalbuminemia, renal failure, third space fluid retention, the elderly, polypharmacy, and transport inhibition are the most critical factors for MTX toxicity. If substitution or temporary discontinuation is not possible, healthcare providers should be aware of interactions, especially in patients with risk factors for MTX toxicity.
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Affiliation(s)
- Fatemeh Jafari
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hesamoddin Hosseinjani
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abolghasem Allahyari
- Division of Hematology and Oncology, Department of Internal medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajad Ataei Azimi
- Division of Hematology and Oncology, Department of Internal medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Reza Askari
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Pharmaceutical Sciences in Persian Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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15
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Di Francesco V, Di Francesco M, Palomba R, Brahmachari S, Decuzzi P, Ferreira M. Towards potent anti-inflammatory therapies in atherosclerosis: The case of methotrexate and colchicine combination into compartmentalized liposomes. J Drug Deliv Sci Technol 2023. [DOI: 10.1016/j.jddst.2023.104179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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16
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Muacevic A, Adler JR, Jalal Y, Ghobrial Y, Ahmed B. Low-Dose Methotrexate Toxicity Presenting as Pancytopenia. Cureus 2022; 14:e32494. [PMID: 36654616 PMCID: PMC9840410 DOI: 10.7759/cureus.32494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 12/16/2022] Open
Abstract
High-dose methotrexate (MTX, 5 g/week) is typically used for the treatment of different malignancies and may be associated with serious side effects, such as acute kidney injury, myelosuppression, and hepatotoxicity. On the other hand, low-dose MTX (10-25 mg/week) is considered to be a safe and effective treatment for autoimmune arthropathies. Toxicity due to low-dose MTX is rare but can present with serious complications, such as pancytopenia. In this report, we present the case of an 82-year-old woman who presented with low-dose, MTX-induced severe pancytopenia and was treated with leucovorin rescue therapy with granulocyte colony-stimulating factor (G-CSF) therapy.
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17
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Ouellette S, Shah R, Razi S, Ashforth G, Wassef C. Fatal low-dose methotrexate toxicity: A case report and literature review. Dermatol Ther 2022; 35:e15945. [PMID: 36259229 DOI: 10.1111/dth.15945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/01/2022]
Abstract
Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis. Here, we report a case of a 67-year-old male with a past medical history of end stage renal disease on peritoneal dialysis and moderate-to-severe psoriasis with psoriatic arthritis presented with abdominal pain, diarrhea, rash, mucositis, and mucocutaneous ulcers and erosions. The patient was taking methotrexate 10 mg weekly without folic acid supplementation and was found to be pancytopenic. Despite treatment, the patient developed multiorgan failure and passed away after 16 days of hospitalization. Myelosuppression is considered the most serious side effect with the highest risk of mortality. Risk factors for toxicity include renal insufficiency, advanced age, lack of folate supplementation, drug interactions, and medication errors. Importantly, serum levels of MTX do not correlate with toxicity; therefore, folinic acid rescue therapy should be started as soon as MTX toxicity is suspected. MTX toxicity is rare with low dose, proper dose scheduling, and adherence to the recommended guidelines. It is imperative that physicians considering therapy with low dose MTX for dermatologic indications take into consideration a patient's risk factors for toxicity and monitor appropriately.
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Affiliation(s)
- Samantha Ouellette
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Rohan Shah
- Division of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Gina Ashforth
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Cindy Wassef
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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18
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Muacevic A, Adler JR. Fatal Manifestations of Methotrexate Overdose in Case of Psoriasis Due to Dosing Error. Cureus 2022; 14:e30041. [PMID: 36381811 PMCID: PMC9637408 DOI: 10.7759/cureus.30041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 11/30/2022] Open
Abstract
For more than 50 years, methotrexate (MTX), when used in low doses, has been one of the most commonly used drugs in the treatment of psoriasis. It has immunosuppressive as well as anti-inflammatory properties. Pancytopenia, hepatic dysfunction, respiratory toxicity, and acute renal failure are some of the reported side effects. This is a case study of a patient who had developed florid symptoms of methotrexate toxicity as a result of erroneous overdosing of methotrexate, which was given to her for psoriasis management.
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19
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Berna R, Rosenbach M, Margolis DJ, Mitra N, Baumrin E. Methotrexate Cutaneous Ulceration: A Systematic Review of Cases. Am J Clin Dermatol 2022; 23:449-457. [PMID: 35486323 DOI: 10.1007/s40257-022-00692-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Methotrexate cutaneous ulceration is a rare methotrexate complication, and has only been described in case reports and case series. OBJECTIVE To document patient characteristics, morphologic features, and mortality risk factors for methotrexate cutaneous ulceration. METHODS A systematic literature review of PubMed and Embase (last date 1 November 2021) was performed with data collected from case reports and case series. This study was limited to cases of cutaneous ulceration; presence of oral ulceration was collected from within these cases. RESULTS 114 cases (men = 57.9%, mean age = 61 years) of methotrexate cutaneous ulceration met inclusion criteria. Psoriasis (69.3%), rheumatoid arthritis (18.4%), and mycosis fungoides (6.1%) were the most common indications for methotrexate use. Morphologies included erosions localized to psoriatic plaques (33.3%), epidermal necrosis/necrolysis (35.1%), localized ulceration (16.7%), and skin-fold erosions (5.3%). Methotrexate dose preceding toxicity varied greatly; median 20 mg/week, interquartile range 15-40 mg/week, range 5-150 mg/week. Most patients had risk factors for serum toxicity (baseline renal dysfunction = 37.8%, concurrent NSAID use = 28.1%, inadequate folic acid use = 89.1%). Thirty percent of cases involved mistakenly high methotrexate doses. Fourteen patients (12%) died. Absence of folic acid use (69% vs. 100%, p value < 0.001), pancytopenia (33% vs. 86%, p value < 0.001), and renal dysfunction at presentation (47% vs. 92%, p value < 0.001) were associated with increased mortality. LIMITATIONS Selection bias present due to abstraction from case reports and case series. CONCLUSION Methotrexate cutaneous ulceration is commonly preceded by dosage mistakes, absence of folic acid supplementation, and concurrent use of nephrotoxic medications. Renal impairment, pancytopenia, and absence of folic acid supplementation are key risk factors for mortality from this adverse medication reaction. Providers should regularly monitor methotrexate dosing adherence, drug-drug interactions, and perform routine laboratory evaluation. Index of suspicion for this toxicity should remain high given the varied clinical presentation and high mortality.
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20
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Ghannoum M, Roberts DM, Goldfarb DS, Heldrup J, Anseeuw K, Galvao TF, Nolin TD, Hoffman RS, Lavergne V, Meyers P, Gosselin S, Botnaru T, Mardini K, Wood DM. Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2022; 17:602-622. [PMID: 35236714 PMCID: PMC8993465 DOI: 10.2215/cjn.08030621] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m2]: 91 patients; low-dose [≤0.5 g/m2]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: (1) suggested against extracorporeal treatments when glucarpidase is not administered; (2) recommended against extracorporeal treatments when glucarpidase is administered; and (3) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: (1) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; (2) extracorporeal treatments remove folinic acid; (3) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and (4) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.
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Affiliation(s)
- Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Darren M. Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia; and St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S. Goldfarb
- Nephrology Division, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children’s Hospital, Lund, Sweden
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | - Tais F. Galvao
- School of Pharmaceutical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Thomas D. Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, Pennsylvania
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Paul Meyers
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, McGill University Emergency Department, Montreal, Quebec and Centre Antipoison du Québec, Quebec, Canada
| | - Tudor Botnaru
- Emergency Department, Lakeshore General Hospital, CIUSSS de l'Ouest-de-l'lle-de-Montreal, McGill University, Montreal, Quebec, Canada
| | - Karine Mardini
- Pharmacy Department, Verdun Hospital, CIUSSS du Sud-Ouest-de-l’ïle-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - David M. Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, United Kingdom
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21
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Silva MM, Ferreira CC, Garcia MA, Pereira E. Methotrexate Pneumonitis After a Low-Dose Medication Error: A Case Report. Cureus 2022; 14:e23078. [PMID: 35464521 PMCID: PMC9001873 DOI: 10.7759/cureus.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Methotrexate is recommended as the first choice of standard drug therapy following the diagnosis of rheumatoid arthritis. Pneumonitis related to methotrexate is a serious, unpredictable adverse event that may become life-threatening. We reported a case of a 68-year-old woman with rheumatoid arthritis that misunderstood the directions for use and took methotrexate daily, instead of weekly, leading to hepatic, hematological, and pulmonary toxicity.Although the histological evaluation was not performed, patient’s clinical presentation, in addition to subsequent investigational findings, supported a diagnosis of pneumonitis resulting from MTX exposure. Toxic dosing over a long period of time along with the concomitant taking of pantoprazole and hypoalbuminemia could have increased the incidence of some adverse events. Concerning pneumonitis related to methotrexate, the toxic dose may have accelerated the pulmonary manifestations, but we do not know if correct dose had been taken, this adverse event would occur. This case enlightened two important issues in rheumatoid arthritis treatment: the possibility of medication errors and the rare, but potentially life-threatening, methotrexate-induced pneumonitis. Improving education and warnings when prescribing and dispensing low-dose methotrexate is essential.
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22
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Hajar T, Latour EJ, Haynes D, Topham C, Hill EE, Simpson EL, Greiling TM. Low-dose methotrexate in dermatology: the utility of serological monitoring in a real-world cohort. J DERMATOL TREAT 2021; 33:2161-2167. [PMID: 34148493 DOI: 10.1080/09546634.2021.1937476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
When prescribing low-dose methotrexate, frequent serological testing is recommended in the dermatologic literature, although much of the supporting data is extrapolated from non-dermatologic conditions. We performed a retrospective cohort study to determine the cumulative incidence and timing of low-dose methotrexate-associated serological abnormalities over the first year of therapy, in a pragmatic cohort of patients with dermatologic compared to non-dermatologic diagnoses. Laboratory values recorded included white blood cell count, hemoglobin, platelet count, estimated glomerular filtration rate, alanine aminotransferase, and aspartate aminotransferase. Among 1376 patients, there were no cases of methotrexate-associated grade 4/very severe lab abnormality or fatality. Baseline risk factors associated with moderate-to-severe lab abnormalities included non-dermatologic diagnoses, low hemoglobin, low estimated glomerular filtration rate, and elevated transaminases. The incidence of moderate-to-severe lab abnormalities was 4.4% among all patients, 3.1% among patients with dermatologic diagnoses, and 2.3% among patients with normal baseline lab values. Lab abnormalities led to discontinuation of therapy in 0.8% of patients. Serious changes did not occur in the first two weeks of therapy. We conclude that the cumulative incidence of low-dose methotrexate-associated lab abnormality was lower in patients with dermatologic diagnoses or normal baseline testing and these factors may be used to adjust monitoring practices.
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Affiliation(s)
- Tamar Hajar
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.,Department of Dermatology,University of Colorado, Denver, CO, USA
| | - Emile J Latour
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Dylan Haynes
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Christina Topham
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.,Department of Dermatology, University of Utah, Salt Lake City, UT, USA
| | - Emma E Hill
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Teri M Greiling
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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23
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Sierocinski E, Angelow A, Mainz A, Walker J, Chenot JF. [Patient safety in the treatment of rheumatic diseases : Laboratory monitoring in methotrexate treatment]. Z Rheumatol 2021; 80:418-424. [PMID: 33709166 PMCID: PMC8189943 DOI: 10.1007/s00393-021-00976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Methotrexate (MTX) is the most commonly prescribed disease-modifying drug in the treatment of rheumatic diseases. Regular laboratory testing is recommended to recognize side effects, such as hepatotoxicity and myelotoxicity as well as decreases in renal function that may cause toxic MTX accumulation. Additionally, folic acid is recommended as prophylaxis against specific side effects. In this study we investigated whether laboratory monitoring and prescription of folic acid took place according to published recommendations. MATERIAL AND METHODS Claims data from the statutory health insurance from 1 January 2009 to 31 December 2013 were retrospectively analyzed. A total of 40,087 adults with a rheumatic diagnosis (ICD10 codes M05-M18), no malignant disease and no previous MTX prescription within 12 months were extracted from the InGef (Institute for Applied Health Research in Berlin, formerly Health Risk Institute) research database. The frequency of recommended laboratory testing, appointments with rheumatologists and the prescription of folic acid prophylaxis were investigated. RESULTS Of the patients 12,451 began treatment with MTX in the observation period. Between 42% and 46% of recommended blood counts, liver values and kidney function tests and 14% of urinalyses were performed according to recommendations. Of the patients 84% were seen regularly by a rheumatologist and 74% received a prescription for prophylactic folic acid. Serious conditions potentially resulting from MTX treatment were observed in 0.7-3.5 cases/1000 person years. DISCUSSION Laboratory monitoring in the context of MTX treatment is carried out less frequently than recommended in the literature. Potential MTX-associated serious complications are rare from a practice perspective. On the one hand solutions are needed for a better coordination of laboratory monitoring. On the other hand more empirical evidence is needed regarding the benefits of laboratory monitoring and the appropriate intervals thereof.
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Affiliation(s)
- Elizabeth Sierocinski
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland.
| | - Aniela Angelow
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland
| | - Armin Mainz
- Hausarztpraxis Korbach, Korbach, Deutschland
| | - Jochen Walker
- InGef - Institut für angewandte Gesundheitsforschung Berlin (früher Health Risk Institute), Berlin, Deutschland
| | - Jean-François Chenot
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland
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24
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Hassan SWU. Pancytopenia Resulting From Low-Dose Methotrexate Use: A Diagnostic Challenge. Cureus 2021; 13:e15193. [PMID: 34178513 PMCID: PMC8221657 DOI: 10.7759/cureus.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Rheumatoid arthritis (RA) is a common autoimmune disease primarily affecting small joints which leads to crippling erosion of the articular cartilage and bone. It is associated with complications related to both its disease course and treatment. Methotrexate (MTX) is a folate antagonist responsible for modulating cell-specific signaling pathways and inhibiting the proinflammatory properties of major cell lineages involved in the pathogenesis of RA. It is considered to be the first-line agent in RA because of its disease-modifying ability and safety profile at low doses. This case report discusses how a middle-aged female presented with severe bone marrow suppression secondary to MTX toxicity, an unusual presentation at the usual low-dose regimen. Her presentation overlapped with several other conditions, especially with Felty’s syndrome, a rare complication of RA, characterized by the triad of splenomegaly, neutropenia, and RA. Other differentials included hemophagocytic lymphohistiocytosis, hematologic neoplasms, drug reaction, and infection. Therefore, it was essential to exclude all possible differentials before initiating therapy. We found the corrected reticulocyte count coupled with a good response to leucovorin to be an effective way to differentiate MTX-induced pancytopenia from other possible hematologic diagnoses without the use of a bone marrow biopsy. Additionally, our case incidentally demonstrated a potential interaction between piperacillin/tazobactam and MTX.
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25
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Asghar M, Shoaib H, Kang W, Tariq I, Chatterjee T. Methotrexate Toxicity: A Simple Solution to a Complex Problem. Cureus 2021; 13:e14364. [PMID: 33972915 PMCID: PMC8106237 DOI: 10.7759/cureus.14364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Methotrexate is a highly effective medication that is the mainstay of treatment for numerous complex dermatological and rheumatological disorders. However, its use requires close monitoring as it has serious side effects that could be fatal if not recognized promptly. Herein, we present an interesting case of methotrexate toxicity leading to a prolonged hospital stay with resultant increase in health care cost and patient dissatisfaction. It remains of pivotal importance for primary care physicians and hospitalists to be aware of its side effect profile. As such, early recognition of methotrexate toxicity can result in earlier initiation of goal-directed therapies, leading to improved outcomes and shorter hospital stay. Patient education and effective communication between health care providers and the patient are of utmost importance in ensuring patient safety.
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Affiliation(s)
- Muhammad Asghar
- Internal Medicine, University of Illinois College of Medicine Peoria, Peoria, USA
| | - Hasan Shoaib
- Internal Medicine, University of Illinois College of Medicine Peoria, Peoria, USA
| | - Woosun Kang
- Internal Medicine, University of Illinois College of Medicine Peoria, Peoria, USA
| | - Irfa Tariq
- Internal Medicine, Sir Ganga Ram Hospital, Lahore, PAK
| | - Tulika Chatterjee
- Internal Medicine, University of Illinois College of Medicine Peoria, Peoria, USA
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26
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Jara-Palacios MA, Chun W, Traub NL. Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report. BMC Rheumatol 2021; 5:5. [PMID: 33573706 PMCID: PMC7879510 DOI: 10.1186/s41927-020-00175-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022] Open
Abstract
Background Low dose methotrexate toxicity rarely occurs, but may present with severe complications, such as pancytopenia, hepatotoxicity, mucositis, and pneumonitis. Known risk factors for methotrexate toxicity include dosing errors, metabolic syndrome, hypoalbuminemia, renal dysfunction, lack of folate supplementation, and the concomitant use of drugs that interfere with methotrexate metabolism. Vitamin B12 deficiency leads to megaloblastic anemia and may cause pancytopenia, but its role in methotrexate toxicity has not been described. Case presentation We present a case of a patient with rheumatoid arthritis who was admitted with febrile neutropenia, pancytopenia, and severe mucositis, likely secondary to low dose methotrexate toxicity. She had multiple factors that potentially contributed to the development of toxicity, including concurrent sulfasalazine use for rheumatoid arthritis. An evaluation of the patient’s macrocytic anemia revealed pernicious anemia. The patient’s illness resolved with cessation of methotrexate and sulfasalazine, leucovorin treatment and vitamin B12 repletion. Conclusions This case illustrates the multiple factors that may potentially contribute to low dose methotrexate toxicity and highlights the importance of testing for vitamin B12 deficiency in rheumatoid arthritis patients with macrocytic anemia. Addressing all the modifiable factors that potentially contribute to low dose methotrexate toxicity may improve outcomes.
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Affiliation(s)
| | - William Chun
- Department of Internal Medicine, WellStar Atlanta Medical Center, Atlanta, GA, USA
| | - Nomi L Traub
- Department of Internal Medicine, WellStar Atlanta Medical Center, Atlanta, GA, USA
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27
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Damayanti D, Pratiwi KD, Nugroho WT. Profile of Psoriasis Vulgaris Patients Treated with Methotrexate at Dr. Soetomo Hospital, Surabaya, 2017–2018. JURNAL BERKALA EPIDEMIOLOGI 2021. [DOI: 10.20473/jbe.v9i12021.70-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Chi H, Wang Z, Meng J, Han P, Zhai L, Feng T, Teng J, Sun Y, Hu Q, Zhang H, Liu H, Cheng X, Ye J, Shi H, Wu X, Zhou Z, Jia J, Wan L, Liu T, Qiao X, Wang M, Wang F, Chen X, Yang C, Su Y. A Cohort Study of Liver Involvement in Patients With Adult-Onset Still's Disease: Prevalence, Characteristics and Impact on Prognosis. Front Med (Lausanne) 2020; 7:621005. [PMID: 33425966 PMCID: PMC7785871 DOI: 10.3389/fmed.2020.621005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/07/2020] [Indexed: 12/21/2022] Open
Abstract
Objective: Adult-onset Still's disease (AOSD) is a systemic disorder commonly accompanied by liver involvement. This study aims to illustrate the detailed information of liver abnormalities in patients with AOSD and evaluate the impact on the prognosis. Methods: A total number of 128 hospitalized patients, who met the Yamaguchi criteria of AOSD in the Department of Rheumatology and Immunology, Ruijin Hospital from July 2016 to August 2019 were consecutively enrolled and followed up. The demographic characteristics, clinical features, laboratory tests, treatments and prognosis were recorded. Correlations of liver function tests (LFTs) with disease activity and laboratory parameters were analyzed by the Spearman test. Risk factors of the refractory AOSD were evaluated by multivariate logistic regression analysis. Results: Liver involvement was presented in 104 (81.3%) patients with AOSD. We observed that 34 (32.7%) patients were with mild elevation, 32 (30.8%) patients were with moderate elevation, and 38 (36.5%) patients were with severe elevation. The majority of elevated ALT, AST and ALP decreased to normal within the range of 2 months, except for GGT. Furthermore, the LFTs were found significantly correlated with disease activity. Besides, we found patients with higher levels of LFTs tended to require more intensive treatments and suffered from poorer prognosis. Multivariate logistic regression analysis showed ALP ≥ 141 IU/L and GGT ≥ 132 IU/L are independent risk factors of refractory AOSD. Conclusion: Liver involvement is common in patients with AOSD, the levels of LFTs are associated with disease activity and related to the treatment strategies and prognosis.
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Affiliation(s)
- Huihui Chi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhihong Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfen Meng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Rheumatology and Immunology, The First People's Hospital of Yancheng, The Forth Affiliated Hospital of Nantong University, Yancheng, China
| | - Pingyang Han
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Rheumatology and Immunology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Limin Zhai
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tienan Feng
- Shanghai Tongren Hospital/Clinical Research Institute, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Clinical Research Promotion and Development Center, Shanghai Shenkang Hospital Development Center, Shanghai, China.,The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Zhang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyao Wu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinchao Jia
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liyan Wan
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Qiao
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xia Chen
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Schicchi A, Scaravaggi G, Petrolini VM, Malovini A, Lonati D, Crevani M, Buscaglia E, Locatelli CA. Poisoning related to therapeutic error in prolonged low-dose methotrexate treatment. Br J Clin Pharmacol 2020; 87:2385-2391. [PMID: 33179288 DOI: 10.1111/bcp.14652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
AIMS To study the predictive factors for the development of clinical manifestations in poisoning due to the erroneous taking of low-dose methotrexate (MTX). METHODS A retrospective observational study was performed. Only cases of erroneous administration in non-oncologic outpatients were included (July 2008-March 2020). RESULTS Forty-one cases were included. All patients were taking MTX for the first time. In 36 cases, patients took MTX daily instead of weekly. In the other five patients, MTX was sold instead of methylergometrine. Clinical manifestations were absent in 12/41 patients (29.3%). All 29 (70.7%) symptomatic patients recognized the medication error when they developed clinical manifestations: dermatological, haematological and gastrointestinal symptoms. Statistical results showed that symptomatic patients were older, received a higher amount of total dose and were treated for longer. Moreover, the probability of being symptomatic increases as a function of age and of total dose. Asymptomatic patients were treated with folinic acid (30 mg/m2 /day) for 5 days. Symptomatic patients were treated with folinic acid together with treatments for the specific clinical manifestations. No patients were treated with glucarpidase. All patients fully recovered. CONCLUSIONS When MTX is prescribed for the first time, it is important to clearly communicate with patients to avoid therapeutic errors. In our experience, age, total dose taken and number of days of assumption are predictive for the presence/absence of clinical manifestations. These parameters must be evaluated together to identify patients needing maximum starting treatment with folinic acid and closer monitoring.
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Affiliation(s)
- Azzurra Schicchi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Giulia Scaravaggi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Valeria M Petrolini
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Alberto Malovini
- Laboratory of Informatics and Systems Engineering for Clinical Research, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Davide Lonati
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Marta Crevani
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Eleonora Buscaglia
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Carlo A Locatelli
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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30
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Singh A, Choudhary R, Chhabra N, Ganguly S, Rathore V. Severe Pancytopenia Following Single Dose Methotrexate In Psoriasis: A Rare And Potentially Lethal Manifestation. Curr Drug Saf 2020; 16:110-113. [PMID: 33106147 DOI: 10.2174/1574886315666201026125149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022]
Abstract
Methotrexate is an anti-metabolite, anti-cancer drug frequently used in the treatment of extensive chronic plaque psoriasis. Psoriatic plaque erosion is a rare toxic side effect of single-dose methotrexate and is described as a sign of impending pancytopenia. Here, we report a case of a 48- year-old male presented with multiple oral and genital erosions, accompanied by fissuring over palm and soles for 5 days. His laboratory tests revealed severe pancytopenia and nephropathy. He had a history of chronic plaque psoriasis for which he took a single dose of 15 mg methotrexate. During the hospital stay, the patient needed folate antagonist, granulocyte colony-stimulating factor (G-CSF), intravenous fluids, blood transfusions, and platelet transfusions. He recovered within 12 days of admission.
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Affiliation(s)
- Ajeet Singh
- Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences Raipur Chhattisgarh, Raipur, India
| | - Ritul Choudhary
- Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences Raipur Chhattisgarh, Raipur, India
| | - Namrata Chhabra
- Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences Raipur Chhattisgarh, Raipur, India
| | - Satyaki Ganguly
- Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences Raipur Chhattisgarh, Raipur, India
| | - Vinay Rathore
- Department of Nephrology, All India Institute of Medical Sciences Raipur Chhattisgarh, Raipur, India
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31
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Ramos PM, Anzai A, Duque-Estrada B, Melo DF, Sternberg F, Santos LDN, Alves LD, Mulinari-Brenner F. Consensus on the treatment of alopecia areata - Brazilian Society of Dermatology. An Bras Dermatol 2020; 95 Suppl 1:39-52. [PMID: 33183894 PMCID: PMC7772599 DOI: 10.1016/j.abd.2020.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/15/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Alopecia areata is a highly frequent disease with an impact on quality of life and several treatment options with little clinical confirmatory evidence. OBJECTIVE To disseminate the recommendations of Brazilian dermatologists with expertise in the treatment of alopecia areata. METHODS Eight specialists with expertise in alopecia areata from different university centers were appointed by the Brazilian Society of Dermatology to reach a consensus on its treatment. Based on the adapted DELPHI methodology, the relevant elements were considered; then, an analysis of recent literature was carried out and the consensus was written down. Consensus on the management of alopecia areata was defined with the approval of at least 70% of the panel. RESULTS/CONCLUSIONS Intralesional injectable corticotherapy was considered the first option for localized disease in adults. In extensive cases with signs of activity, systemic corticosteroid therapy should be considered and can be used together with immunosuppressants (corticosteroid-sparing agents). The use of an immunosensitizer (diphencyprone) is an option for stable long-term cases. Evaluation of side effects is as important as the rate of hair regrowth.
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Affiliation(s)
- Paulo Müller Ramos
- Department of Dermatology and Radiotherapy, Universidade Estadual Paulista, Botucatu, SP, Brazil.
| | - Alessandra Anzai
- Department of Dermatology, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Bruna Duque-Estrada
- Centro de Estudos dos Cabelos, Instituto de Dermatologia Prof. Rubem David Azulay, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Daniel Fernandes Melo
- Department of Dermatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Flavia Sternberg
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Leopoldo Duailibe Nogueira Santos
- Department of Medicine, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Dermatology and Allergology, Hospital do Servidor Público Municipal, São Paulo, SP, Brazil
| | - Lorena Dourado Alves
- Department of Tropical Medicine and Dermatology, Universidade Federal de Goiás, Goiânia, GO, Brazil
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32
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Tokunaga T, Hashimoto H, Yoshida Y, Sugimoto T, Mokuda S, Kosaka Y, Shimizu R, Hirata S, Kumagai T, Komoto K, Wada H, Sugiyama E. Immunoglobulin D-kappa multiple myeloma in a patient with rheumatoid arthritis: a case report and review of the literature. Mod Rheumatol Case Rep 2020; 5:22-28. [PMID: 32985955 DOI: 10.1080/24725625.2020.1826651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 77-year-old Japanese woman with a 21-year history of seropositive, erosive rheumatoid arthritis (RA) and a 10-year history of methotrexate (MTX) therapy was admitted with malaise and mild consciousness disturbance. Laboratory data showed hypercalcemia, acute kidney injury, normocytic anaemia, and thrombocytopenia. As we first assumed drug-induced toxicity by MTX and eldecalcitol, both were discontinued and leucovorin rescue therapy and calcitonin were administered. However, her condition continued to worsen. Serum protein electrophoresis showed only a small M-peak, immunoelectrophoresis of both the serum and urine demonstrated Bence-Jones kappa (κ) type monoclonal protein without immunoglobulin heavy chain, and bone marrow examination revealed proliferation of plasma cells. We diagnosed her with Bence-Jones κ type multiple myeloma (MM) and transferred her to the department of haematology of a higher order medical institution. Conclusively, the diagnosis of immunoglobulin (Ig) D-κ type MM, a rare variant of this disorder, was determined in accordance with serum immunofixation. Several previous studies have suggested that pre-existing RA is a risk factor for MM. Although IgD MM is characterised by its clinical severity and poor prognosis compared to other subtypes, it is often misdiagnosed or mistaken as light chain type MM, as in the present case, because of the low level of IgD M-protein, resulting in delayed diagnosis. Physicians must take MM into consideration as a differential diagnosis when inactive RA patients present with inexplicable elevated calcium, renal failure, anaemia, and bone lesion symptoms and should be aware of IgD MM to establish the correct diagnosis promptly.
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Affiliation(s)
- Tadahiro Tokunaga
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan.,Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroo Hashimoto
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoko Kosaka
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Risa Shimizu
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomoyo Kumagai
- Department of Clinical Laboratory, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Kiichi Komoto
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Hideho Wada
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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33
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Gisondi P, Bellinato F, Bruni M, De Angelis G, Girolomoni G. Methotrexate vs secukinumab safety in psoriasis patients with metabolic syndrome. Dermatol Ther 2020; 33:e14281. [DOI: 10.1111/dth.14281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Paolo Gisondi
- Section of Dermatology and Venereology, Department of Medicine University of Verona Verona Italy
| | - Francesco Bellinato
- Section of Dermatology and Venereology, Department of Medicine University of Verona Verona Italy
| | - Manfredo Bruni
- Section of Dermatology and Venereology, Department of Medicine University of Verona Verona Italy
| | - Giulia De Angelis
- Section of Dermatology and Venereology, Department of Medicine University of Verona Verona Italy
| | - Giampiero Girolomoni
- Section of Dermatology and Venereology, Department of Medicine University of Verona Verona Italy
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34
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Young G, Tolla AS, Grinenko O, Karanec K. Neuropsychiatric manifestations in adult-onset Still’s disease. BMJ Case Rep 2020; 13:13/9/e235956. [DOI: 10.1136/bcr-2020-235956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Adult-onset Still’s disease (AOSD) is an uncommon inflammatory condition characterised by a triad of fevers, arthralgias and a salmon-coloured rash. It is also strongly associated with high ferritin levels, whose role in its pathogenesis is not entirely clear. Central nervous system (CNS) manifestations are exceedingly rare in this disease, accounting for only a handful of reported cases. Herein, we describe a case of a 63-year-old woman who developed new-onset psychiatric symptoms in the months preceding her diagnosis. 2 months after her diagnosis, she experienced an exacerbation of psychiatric symptoms followed by new-onset seizures in conjunction with an acute lung infection. In addition, we discuss two other previously reported cases of AOSD patients with psychiatric symptoms as their initial presentation.
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35
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Di Francesco V, Gurgone D, Palomba R, Ferreira MFM, Catelani T, Cervadoro A, Maffia P, Decuzzi P. Modulating Lipoprotein Transcellular Transport and Atherosclerotic Plaque Formation in ApoE -/- Mice via Nanoformulated Lipid-Methotrexate Conjugates. ACS APPLIED MATERIALS & INTERFACES 2020; 12:37943-37956. [PMID: 32805983 PMCID: PMC7453397 DOI: 10.1021/acsami.0c12202] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/28/2020] [Indexed: 05/02/2023]
Abstract
Macrophage inflammation and maturation into foam cells, following the engulfment of oxidized low-density lipoproteins (oxLDL), are major hallmarks in the onset and progression of atherosclerosis. Yet, chronic treatments with anti-inflammatory agents, such as methotrexate (MTX), failed to modulate disease progression, possibly for the limited drug bioavailability and plaque deposition. Here, MTX-lipid conjugates, based on 1,2-distearoyl-sn-glycero-3-phosphoethanolamine (DSPE), were integrated in the structure of spherical polymeric nanoparticles (MTX-SPNs) or intercalated in the lipid bilayer of liposomes (MTX-LIP). Although, both nanoparticles were colloidally stable with an average diameter of ∼200 nm, MTX-LIP exhibited a higher encapsulation efficiency (>70%) and slower release rate (∼50% at 10 h) compared to MTX-SPN. In primary bone marrow derived macrophages (BMDMs), MTX-LIP modulated the transcellular transport of oxLDL more efficiently than free MTX mostly by inducing a 2-fold overexpression of ABCA1 (regulating oxLDL efflux), while the effect on CD36 and SRA-1 (regulating oxLDL influx) was minimal. Furthermore, in BMDMs, MTX-LIP showed a stronger anti-inflammatory activity than free MTX, reducing the expression of IL-1β by 3-fold, IL-6 by 2-fold, and also moderately of TNF-α. In 28 days high-fat-diet-fed apoE-/- mice, MTX-LIP reduced the mean plaque area by 2-fold and the hematic amounts of RANTES by half as compared to free MTX. These results would suggest that the nanoenhanced delivery to vascular plaques of the anti-inflammatory DSPE-MTX conjugate could effectively modulate the disease progression by halting monocytes' maturation and recruitment already at the onset of atherosclerosis.
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Affiliation(s)
- Valentina Di Francesco
- Laboratory
of Nanotechnology for Precision Medicine, Fondazione Istituto Italiano di Tecnologia, Via Morego 30, 16163 Genoa, Italy
- Department
of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Via Opera Pia, 13, 16145 Genoa, Italy
| | - Danila Gurgone
- Centre
for Immunobiology, Institute of Infection, Immunity and Inflammation,
College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, United Kingdom
- Department
of Pharmacy, University of Naples Federico
II, Naples 80131, Italy
| | - Roberto Palomba
- Laboratory
of Nanotechnology for Precision Medicine, Fondazione Istituto Italiano di Tecnologia, Via Morego 30, 16163 Genoa, Italy
| | | | - Tiziano Catelani
- Electron
Microscopy Facility, Istituto Italiano di
Tecnologia, via Morego
30, Genova 16163, Italy
| | - Antonio Cervadoro
- Laboratory
of Nanotechnology for Precision Medicine, Fondazione Istituto Italiano di Tecnologia, Via Morego 30, 16163 Genoa, Italy
| | - Pasquale Maffia
- Centre
for Immunobiology, Institute of Infection, Immunity and Inflammation,
College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, United Kingdom
- Department
of Pharmacy, University of Naples Federico
II, Naples 80131, Italy
- Institute
of Cardiovascular and Medical Sciences, College of Medical, Veterinary
and Life Sciences, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Paolo Decuzzi
- Laboratory
of Nanotechnology for Precision Medicine, Fondazione Istituto Italiano di Tecnologia, Via Morego 30, 16163 Genoa, Italy
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36
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Wang G, Peng X. A Review of Clinical Applications and Side Effects of Methotrexate in Ophthalmology. J Ophthalmol 2020; 2020:1537689. [PMID: 32850138 PMCID: PMC7439192 DOI: 10.1155/2020/1537689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022] Open
Abstract
Methotrexate (MTX) is a folate analog widely used against a range of diseases including malignancies and autoimmune disorders. Its high effectiveness-price ratio also won extensive application in ophthalmology. On the other hand, although MTX has an excellent pharmacological efficacy, MTX associated side effects in clinical use, which vary from patient to patient, are nonnegligible. There is no comparatively systematic review on MTX associated side effects and its risk factors. This review aimed to reveal novel clinical approaches of MTX and its adverse effects in order to provide a reference for ophthalmic scholars in clinical application of MTX.
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Affiliation(s)
- Ge Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Xiaoyan Peng
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
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37
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AKDAĞ İ, ERSOY A. Development of pancytopenia after single low-dose methotrexate therapy in patients with chronic kidney disease: a review of the literature. TURKISH JOURNAL OF INTERNAL MEDICINE 2020. [DOI: 10.46310/tjim.766086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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38
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Correal ML, Camplesi AC, Anai LA, Bertolo PHL, Vasconcelos RDO, Santana ÁE. Toxicity of a methotrexate metronomic schedule in Wistar rats. Res Vet Sci 2020; 132:379-385. [PMID: 32755752 DOI: 10.1016/j.rvsc.2020.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/21/2022]
Abstract
Metronomic chemotherapy is a relevant strategy that uses low doses of antineoplastic drugs for sustained periods to control tumor growth, an alternative frequently utilized in veterinary patients. This work aimed to evaluate the toxic effects of a metronomic oral dose of methotrexate (MTX) for 45 days in tumor-free Wistar rats when compared with control animals. Clinical alterations, body weight, food, and water intake were monitored daily, and bone marrow suppression, hematological, biochemical, and histopathological analyses were performed at three points (days 30, 45, and 60). MTX-treated animals did not demonstrate severe systemic involvement. At 30 days, compared with control animals, MTX-treated animals showed significant leukocytosis (11.9 ± 2.3 vs. 7.8 ± 0.2 106/μL; P < .05) and augmentation of immature myeloid populations from bone marrow (9.0 ± 0.8 vs. 6.5 ± 1.5%; P < .05), and at 60 days, treated animals showed significant neutrophilia (35.0 ± 11.0 vs. 23.00 ± 3.0%; P < .05), depletion of bone marrow lymphocytes (8.2 ± 0.7 vs. 11.5 ± 1.9%; P < .05), and immature myeloid populations (7.2 ± 0.7 vs. 8.3 ± 0.6%; P < .05). At a histopathological level, splenic hypoplasia and respiratory inflammatory lesions were significant when compared with control animals, presenting mild to moderate myelotoxicity, immune suppression, and associated clinical compromise that persisted beyond treatment withdrawal. This suggested that MTX metronomic toxicity should not be neglected owing to the observed residual side-effects and special care should be taken regarding myelosuppression.
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Affiliation(s)
- María Lucía Correal
- Department of Veterinary Clinic and Surgery, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
| | - Annelise Carla Camplesi
- Department of Veterinary Clinic and Surgery, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
| | - Letícia Abrahão Anai
- Department of Veterinary Clinic and Surgery, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
| | - Paulo Henrique Leal Bertolo
- Department of Veterinary Pathology, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
| | - Rosemeri de Oliveira Vasconcelos
- Department of Veterinary Pathology, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
| | - Áureo Evangelista Santana
- Department of Veterinary Clinic and Surgery, School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Via de Acesso Prof. Paulo Donato Castellane s/n, CEP 14884-900 Jaboticabal/SP, Brazil.
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39
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Leonardo N, Lester S, Graham M, Barrett C, Whittle S, Rowett D, Buchbinder R, Hill CL. Selection and perception of methotrexate treatment information in people with rheumatoid arthritis. Int J Rheum Dis 2020; 23:805-812. [DOI: 10.1111/1756-185x.13833] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Affiliation(s)
| | - Susan Lester
- The Queen Elizabeth Hospital Adelaide SA Australia
- Discipline of Medicine University of Adelaide Adelaide SA Australia
| | | | - Claire Barrett
- Redcliffe Hospital Redcliffe Qld Australia
- Discipline of Medicine University of Queensland Brisbane Qld Australia
| | | | - Debra Rowett
- School of Pharmacy and Medical Sciences University of South Australia Adelaide SA Australia
- Drug and Therapeutics Information Service SALHN Adelaide SA Australia
| | - Rachelle Buchbinder
- Cabrini Institute Melbourne Vic. Australia
- Monash University Melbourne Vic. Australia
| | - Catherine L. Hill
- The Queen Elizabeth Hospital Adelaide SA Australia
- Discipline of Medicine University of Adelaide Adelaide SA Australia
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40
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Tu X, Chen R, Huang G, Lu N, Chen Q, Bai X, Li B. Factors Predicting Severe Myelosuppression and Its Influence on Fertility in Patients with Low-Risk Gestational Trophoblastic Neoplasia Receiving Single-Agent Methotrexate Chemotherapy. Cancer Manag Res 2020; 12:4107-4116. [PMID: 32581584 PMCID: PMC7276201 DOI: 10.2147/cmar.s252664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the potential factors to predict severe myelosuppression among low-risk gestational trophoblastic neoplasia (GTN) patients with single-agent methotrexate (MTX) chemotherapy. To analyze reproductive outcomes of patients with or without severe myelosuppression after achieving complete remission (CR). Patients and Methods The retrospective study included 319 low-risk GTN patients registered from January 2008 to December 2018 in our hospital. Patients were divided into two groups according to myelosuppression grading. Their clinical data and reproductive outcomes were compared and analyzed. Results A higher proportion of patients in group A received second-line chemotherapy than group B (P<0.001). The number of total chemotherapy courses was more in group A than group B (P=0.001), while the number of MTX chemotherapy courses was more in group B than group A (P=0.001). When the joint predictor of pretreatment albumin (ALB) was not more than 44.5 g/L, pretreatment serum creatinine (Scr) was not less than 75.6 μmol/L, and the number of MTX chemotherapy courses was not less than four, there was a moderate predictive value. There was no significant difference of reproductive outcomes between the two groups after achieving CR. Conclusion Although some patients developed severe myelosuppression, MTX was still the effective first-line treatment for low-risk GTN patients. Patient’s pretreatment ALB was not more than 44.5 g/L, pretreatment Scr was not less than 75.6 μmol/L, and the number of MTX chemotherapy courses not less than four could be used as combined predictors to recognize the risk of severe myelosuppression. Severe myelosuppression had no significant adverse influence on fertility after achieving CR.
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Affiliation(s)
- Xiaoyu Tu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Ruizhe Chen
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Genping Huang
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Nanjia Lu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Qin Chen
- Department of Pathology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Xiaoxia Bai
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Baohua Li
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
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41
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Wang J, Yin J, Li W, Xiao C, Han J, Zhou F. Association between SLCO1A2 genetic variation and methotrexate toxicity in human rheumatoid arthritis treatment. J Biochem Mol Toxicol 2020; 34:e22513. [DOI: 10.1002/jbt.22513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/10/2020] [Accepted: 04/07/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Jiayi Wang
- Department of Rheumatology, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Jun Yin
- Department of NephrologyThe Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University Wuxi Jiangsu China
| | - Wei Li
- Department of Rheumatology, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Chunyuan Xiao
- Department of Rheumatology, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Jie Han
- Department of Rheumatology, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Fanfan Zhou
- Sydney Pharmacy SchoolThe University of Sydney Sydney New South Wales Australia
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42
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Krasselt M, Baerwald C, Petros S, Seifert O. Mortality of Sepsis in Patients With Rheumatoid Arthritis: A Single-Center Retrospective Analysis and Comparison With a Control Group. J Intensive Care Med 2020; 36:766-774. [PMID: 32249644 PMCID: PMC8165740 DOI: 10.1177/0885066620917588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION/BACKGROUND Patients with rheumatoid arthritis (RA) have a high risk of infections that may require intensive care unit (ICU) admission in case of resulting sepsis. Data regarding the mortality of these patients are very limited. This study investigated clinical characteristics and outcomes of patients with RA admitted to the ICU for sepsis and compared the results to a control cohort without RA. METHODS All patients with RA as well as sex-, age-, and admission year-matched controls admitted to the ICU of a university hospital for sepsis between 2006 and 2019 were retrospectively analyzed. Mortality was calculated for both the groups, and multivariate logistic regression was used to determine independent risk factors for sepsis mortality. The positive predictive value of common ICU scores was also investigated. RESULTS The study included 49 patients with RA (mean age 67.2 ± 9.0 years, 63.3% females) and 51 matched controls (mean age 67.4 ± 9.5 years, 64.7% females). Among the patients with RA, 42.9% (n = 21) were treated with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) and 30.6% (n = 15) received glucocorticoids only. Seven (14.3%) patients received biologic (b) DMARDs. The hospital mortality was higher among patients with RA (42.9% vs 15.7%, P = .0016). Rheumatoid arthritis was independently associated with mortality in multivariate logistic regression (P = .001). In patients with RA, renal replacement therapy (P = .024), renal failure (P = .027), and diabetes mellitus (P = .028) were independently associated with mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were good predictors of sepsis mortality in patients with RA (APACHE II area under the curve [AUC]: 0.78, P = .001; SAPS II AUC: 0.78, P < .001; SOFA AUC 0.78, P < .001), but their predictive power was higher among controls. CONCLUSIONS Hospital sepsis mortality was higher in patients with RA than in controls. Rheumatoid arthritis itself is independently associated with an increased sepsis mortality. Renal replacement therapy, renal failure, and diabetes were associated with an increased mortality. Common ICU scores were less well predictors of sepsis mortality in patients with RA compared to non-RA controls.
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Affiliation(s)
- Marco Krasselt
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
| | - Christoph Baerwald
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - Olga Seifert
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
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43
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Cytopénies secondaires au méthotrexate à faible dose. Ann Dermatol Venereol 2020; 147:252-253. [DOI: 10.1016/j.annder.2020.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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44
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Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol 2020; 82:1445-1486. [PMID: 32119894 DOI: 10.1016/j.jaad.2020.02.044] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. In this guideline, we focus the discussion on systemic, nonbiologic medications for the treatment of this disease. We provide detailed discussion of efficacy and safety for the most commonly used medications, including methotrexate, cyclosporine, and acitretin, and provide recommendations to assist prescribers in initiating and managing patients on these treatments. Additionally, we discuss newer therapies, including tofacitinib and apremilast, and briefly touch on a number of other medications, including fumaric acid esters (used outside the United States) and therapies that are no longer widely used for the treatment of psoriasis (ie, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus).
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Affiliation(s)
| | - Joel M Gelfand
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Kelly M Cordoro
- Department of Dermatology, University of California, San Francisco School of Medicine, San Diego, California
| | | | | | | | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | | | | | - Matthew Kiselica
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | | | - Neil J Korman
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason Lichten
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Nehal N Mehta
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Arun L Pathy
- Colorado Permanente Medical Group, Centennial, Colorado
| | | | | | - Reena N Rupani
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Bruce E Strober
- Central Connecticut Dermatology, Cromwell, Connecticut; Yale University, New Haven, Connecticut
| | - Elliot B Tapper
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Emily B Wong
- San Antonio Uniformed Services Health Education Consortium, Joint-Base San Antonio, Texas
| | - Jashin J Wu
- Dermatology Research and Education Foundation, Irvine, California
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45
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Salama N, Blgozah S. Normal Male Reproductive Hormones And Sperm Parameters In Adult-Onset Still's Disease- A Case Report And Literature Review. Int Med Case Rep J 2019; 12:345-348. [PMID: 31814777 PMCID: PMC6858797 DOI: 10.2147/imcrj.s215787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/26/2019] [Indexed: 11/23/2022] Open
Abstract
Adult-onset Still’s disease (AOSD) is an uncommon systemic auto-inflammatory disease. It can affect multiple body organs. Herein, we report the reproductive hormone and semen profiles in a male with AOSD. A 23-year-old male with already diagnosed and controlled AOSD requested a premarital check-up on his fertility potential. He was kept on a maintenance treatment protocol for the disease including prednisolone, methotrexate, folic acid, and vitamin D3. His reproductive hormones and semen profiles were found normal. The questionable enhancing effects of the different elements of the treatment protocol on the tested reproductive indices were discussed and refuted. To the best of our knowledge, this is the first case report describing the impact of AOSD on male fertility potential which was not deleterious in the reported case.
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Affiliation(s)
- Nader Salama
- Department of Urology, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Saeed Blgozah
- Department of Urology, Hadramout Faculty of Medicine, Hadhramout University, Mukalla, Yemen
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46
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Tan Z, Liu W, Guo H, Hu K, Zhao R. Severe toxic effects of low-dose methotrexate treatment for placenta accreta in a patient with methylenetetrahydrofolate reductase mutations. J Clin Pharm Ther 2019; 45:214-217. [PMID: 31545520 DOI: 10.1111/jcpt.13050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/04/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Low-dose methotrexate (LDMTX) has been widely used for many decades in clinical settings, with good safety profiles compared with those of high-dose methotrexate. LDMTX is also used as one of the off-label conservative therapies in treating placenta accreta (PA). Until now, only a few mild adverse drug reactions (ADRs) have been published after short-term use of LDMTX, and no severe cases have been reported. CASE SUMMARY We present a case of a 30-year-old female who developed acute severe oral ulcerative mucositis with degree IV myelosuppression and degree III hepatic injury, after three doses of LDMTX to treat placenta accrete. The symptoms gradually improved after leucovorin rescue and supportive treatments. WHAT IS NEW AND CONCLUSION The present case provides the first severe ADR report for the short-term use of LDMTX for treating PA, indicating that potentially life-threatening complications can also occur when using LDMTX. Early recognition and immediate leucovorin rescue could result in a favourable outcome.
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Affiliation(s)
- Zhiyuan Tan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Therapeutic Drug Monitoring and Clinical Toxicity Center, Peking University, Beijing, China
| | - Hua Guo
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Kai Hu
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Therapeutic Drug Monitoring and Clinical Toxicity Center, Peking University, Beijing, China
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Owumi SE, Ajijola IJ, Agbeti OM. Hepatorenal protective effects of protocatechuic acid in rats administered with anticancer drug methotrexate. Hum Exp Toxicol 2019; 38:1254-1265. [DOI: 10.1177/0960327119871095] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The efficacy of methotrexate (MTX) as an anticancer drug is limited by some adverse effects including hepatic and renal toxicities. The present study investigated the possible protective effect of protocatechuic acid (PCA), a phenolic phytochemical widely present in several edible vegetables and fruits, on hepatorenal toxicity associated with MTX treatment in rats. Male Wistar rats were randomly assigned to five groups ( n = 10), namely control, MTX alone (20 mg/kg), PCA alone (50 mg/kg), and rats that were coadministered MTX and PCA at 25 and 50 mg/kg. The MTX was administered as a single intraperitoneal dose on the first day, whereas PCA treatment lasted 7 days. Results indicated that PCA significantly ( p < 0.05) abrogated MTX-mediated elevation in indices of hepatorenal toxicity. Furthermore, PCA protected against MTX-induced decreases in glutathione level and antioxidant enzyme activities as well as the increase in reactive oxygen and nitrogen species and lipid peroxidation in the liver and kidney of the treated rats. Administration of PCA markedly abated MTX-induced increases in interleukin-1β, tumor necrosis factor alpha, and caspase 3 activity in the rats. The biochemical data on the hepatorenal protective effects of PCA were well supported by the histological data. Collectively, PCA protected against MTX-induced hepatorenal toxicity via antioxidant, anti-inflammatory, and antiapoptotic mechanisms.
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Affiliation(s)
- SE Owumi
- Department of Biochemistry, Cancer Research and Molecular Biology Laboratory, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - IJ Ajijola
- Department of Biochemistry, Cancer Research and Molecular Biology Laboratory, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - OM Agbeti
- Department of Biochemistry, Cancer Research and Molecular Biology Laboratory, College of Medicine, University of Ibadan, Ibadan, Nigeria
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48
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Lucas CJ, Dimmitt SB, Martin JH. Optimising low-dose methotrexate for rheumatoid arthritis-A review. Br J Clin Pharmacol 2019; 85:2228-2234. [PMID: 31276602 DOI: 10.1111/bcp.14057] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Methotrexate at low doses (5-25 mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.
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Affiliation(s)
- Catherine J Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Simon B Dimmitt
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Western Australia, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
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Abstract
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.
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50
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Bhatia R, Hazarika N, Chandrasekaran D, Joshi P. Bleeding erosions in a man with psoriasis. Postgrad Med J 2019; 96:53-54. [PMID: 31326941 DOI: 10.1136/postgradmedj-2019-136499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/07/2019] [Accepted: 07/09/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Riti Bhatia
- Department of Dermatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Neirita Hazarika
- Department of Dermatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Divya Chandrasekaran
- Department of Dermatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Prashant Joshi
- Pathology, All India Institute of Medical Sciences, Rishikesh, India
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