Methotrexate: anti-inflammatory or antiproliferative?

Methotrexate Hepatotoxicity and the Impact of Nonalcoholic Fatty Liver Disease

Methotrexate (MTX) is commonly used to treat individuals with rheumatological and dermatologic disorders. Current American College of Rheumatology (ACR) and American Association of Dermatology (AAD) guidelines identify diabetes and obesity as risk factors for MTX-induced liver injury. Both diabetes and obesity are components of the metabolic syndrome, and are also risk factors for nonalcoholic fatty liver disease (NAFLD). NAFLD affects approximately 40% of the U.S. population, and those with more advanced NAFLD (i.e., nonalcoholic steatohepatitis with or without fibrosis) are likely to develop progressive liver disease. As such, individuals who are treated with MTX may need to be screened for advanced NAFLD, as this may put them at an increased risk of MTX-induced liver injury. In this mini-review, we review the current ACR and AAD guidelines on MTX hepatotoxicity, discuss the evidence (or lack thereof) of the impact of metabolic risk factors on MTX-induced liver injury and highlight the areas that need further research.

Methotrexate for psoriasis: current European practice. A postal survey

The aim of this survey was to determine current practice throughout Europe regarding use and monitoring of methotrexate therapy for psoriasis. A structured questionnaire with questions on methotrexate prescribing and monitoring was mailed to 150 dermatologists in 32 European countries in June 2002. Dermatologists' names were chosen at random from the 2001 European Academy of Dermatology and Venereology membership directory. A reply was received from 69 dermatologists of whom 59 prescribed methotrexate regularly. In those patients receiving systemic treatment for psoriasis, methotrexate was the most widely used drug (4.4 patients of every 10) followed by acitretin (3.2) and cyclosporin (1.6). Myelosuppression was the commonest reported fatal side-effect of methotrexate (eight of a total of 10 cases). None of the respondents routinely requested a baseline liver biopsy before starting methotrexate treatment and of every 10 of their patients on long-term methotrexate it was estimated that less than two had had a liver biopsy some time during treatment. Serum measurement of the amino-terminal peptide of type III procollagen (PIIINP) was used routinely to detect liver fibrosis by 12 (20%) of the 59 respondents who regularly prescribed methotrexate. This survey demonstrates that, despite the advent of new therapies, methotrexate retains a central role in the treatment of severe psoriasis in Europe. The responses demonstrated variation in, among others, the methotrexate dose regimen utilized and the use of folate supplementation, confirming the need for randomized controlled studies to address these issues.

Tratamento sistêmico da psoríase - Parte I: metotrexato e acitretina

Embora a fisiopatologia da psoríase ainda não esteja totalmente esclarecida e permaneçam dúvidas quanto à natureza dos antígenos que levam à ativação do linfócito T e quanto ao papel dos mecanismos reguladores dos surtos e da resolução da inflamação, são inegáveis os avanços terapêuticos das últimas décadas. Além do surgimento de novos medicamentos, a melhor utilização de tratamentos clássicos e a valorização do impacto da terapêutica na qualidade de vida dos pacientes têm contribuído para a diminuição dos índices de morbidade da doença. Este artigo de EMC-D aborda a utilização de metotrexato e acitretina no tratamento da psoríase. A utilização de outros imunomoduladores e de terapias biológicas será objeto de próximo capítulo.

Monitoring methotrexate-induced hepatic fibrosis in patients with psoriasis: are serial liver biopsies justified?

BACKGROUND

Reports that up to 26% of subjects with psoriasis develop cirrhosis have led to a recommendation of serial liver biopsies after each cumulative dose of 1500 mg of methotrexate.

AIM

To evaluate the progression of liver injury in patients with psoriasis and the impact of monitoring by liver biopsy on their management.

METHODS

One hundred and twenty-one liver biopsies from 66 subjects (aged 11-79 years) with psoriasis, receiving a median cumulative dose of 3206 mg of methotrexate over a period of 280.5 weeks, were evaluated.

RESULTS

The assessment of advanced fibrosis according to the Ishak system (>or= 4) correlated perfectly with that of the Scheuer system (>or= 3) and poorly with that of the Roenigk scale (>or= 3b) (r2 = 1.0 and 0.31, respectively). Two of 24 pre-treatment biopsies showed advanced fibrosis and both subjects were heavy drinkers. The cumulative probabilities of advanced fibrosis (Ishak >or= 4) were 0%, 2.6%, 2.6%, 8.2% and 8.2% at cumulative doses of 1500, 3000, 4500, 5000 and 6000 mg, respectively. None of the subjects developed cirrhosis during follow-up or discontinued therapy on the basis of liver biopsy findings.

CONCLUSIONS

Advanced hepatic fibrosis with low-dose methotrexate therapy is much less frequent than previously reported. Pre-treatment or monitoring liver biopsies in accordance with the current guidelines have little impact on patient management.

[Methotrexate in dermatology: pharmacology, indications, applications and prudent use]

High dosage methotrexate is currently used in the treatment of malignancies. When used at low- or moderate doses, methotrexate has antiproliferative and antiinflammatory effects and is a useful drug in skin diseases. The aim of this review is to describe pharmacology, indications, adverse effects and practical use in Dermatology. Pharmacodynamics of methotrexate is especially related to antifolic activity. Methotrexate is officially approved in the treatment of severe psoriasis, but many other proliferative or inflammatory diseases with cutaneous manifestations may benefit from this drug, usually in association with corticosteroids. The use of methotrexate needs some precautions and a precise follow-up to minimise the risk of severe adverse effects. However, efficacy of methotrexate was reported in open and retrospective small size studies. Prospective and comparative trials are required to confirm the indications, advantages and tolerance of methotrexate in dermatology.

Psoriasis

Psoriasis is a common skin condition that can be controlled in nearly every patient. The diagnosis of psoriasis is generally made on the basis of identification of skin lesions of characteristic morphology in characteristic locations. A variety of treatments and resources are available to patients with psoriasis and to the physicians who treat them. Development of an appropriate treatment regimen is facilitated by categorization of psoriasis into localized versus generalized forms.

Methotrexate for psoriasis

Methotrexate is an effective antipsoriatic agent and has been widely used to treat severe psoriasis since the 1960s. It is especially useful in acute generalized pustular psoriasis, psoriatic erythroderma, psoriatic arthritis and for extensive chronic plaque psoriasis in patients who are inadequately controlled by topical therapy alone. It has not, however, been formally compared with other systemic treatments for severe psoriasis such as cyclosporin, retinoids or photochemotherapy with psoralen and UVA (PUVA), but in comparison with these other therapies it is inexpensive, with correct use, its safety profile is favourable. In summary, therefore, it can be used as a short-term option to gain control of unstable psoriasis such as pustular psoriasis or erythroderma before returning to other modes of treatment, or more often, as long-term maintenance treatment. The most important potential side-effect is acute myelosuppression, which is the cause of most of the rare deaths attributable to this therapy for psoriasis. Myelosuppression is more likely in the elderly, in patients with renal impairment and/or folate depletion, and with overdose or drug interactions. Long-term therapy carries with it a risk of liver fibrosis which is related to the dosage regimen employed, and is increased by exposure to other hepatic toxins, particularly alcohol. The correlation between the risk of development of liver fibrosis, cumulative lifetime dose and duration of treatment with methotrexate is not clear-cut, but may have been overstated in some studies.

Low-dose methotrexate treatment in elderly patients with bullous pemphigoid

BACKGROUND

Various treatments have been used for elderly patients with bullous pemphigoid. The most common is moderate-dose to high-dose prednisone, either alone or in combination with other oral or topical agents.

OBJECTIVE

The aim of this study was to evaluate the efficacy of low-dose methotrexate as a steroid-sparing agent in patients with bullous pemphigoid. METHODS. A retrospective chart review of 34 patients with bullous pemphigoid seen from 1989 through the first half of 1993 was conducted. The diagnosis of bullous pemphigoid was confirmed by direct or indirect immunofluorescence microscopy, or salt-split skin sections. Eight of 34 elderly (> 60 years old) patients with therapy-resistant bullous pemphigoid received low-dose weekly methotrexate (average, 5 to 10 mg) in combination with oral prednisone.

RESULTS

Patients who received combination therapy required significantly lower (p < or = 0.02) doses of prednisone to control their disease at 1 month compared with baseline doses.

CONCLUSION

In this elderly patient population the side effect profile of the methotrexate was acceptable and well tolerated. We therefore recommend methotrexate and low-dose corticosteroid as first-line combination therapy for selected elderly patients with bullous pemphigoid.

Low-dose weekly methotrexate for unusual neutrophilic vascular reactions: cutaneous polyarteritis nodosa and Behçet's disease

Low-dose weekly methotrexate therapy has been used to treat patients with psoriasis for more than 20 years. This regimen has also been used to treat rheumatoid arthritis, inflammatory bowel disease, primary sclerosing cholangitis, and corticosteroid-dependent asthma. We report two patients with Behçet's disease with cutaneous neutrophilic vascular reactions and three with cutaneous polyarteritis nodosa who responded dramatically to low-dose weekly methotrexate therapy.