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Yessirkepov M, Kocyigit BF, Zhakipbekov K, Adilbekov E, Sultanbekov K, Akaltun MS. Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction. Rheumatol Int 2024:10.1007/s00296-024-05602-8. [PMID: 38693253 DOI: 10.1007/s00296-024-05602-8] [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: 02/22/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.
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Affiliation(s)
- Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana City Research and Training Hospital, Adana, Türkiye, Turkey
| | - Kairat Zhakipbekov
- Department of Organization and Management and Economics of Pharmacy and Clinical Pharmacy, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | | | - Kassymkhan Sultanbekov
- Department Social Health Insurance and Public Health, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Mazlum Serdar Akaltun
- Faculty of Medicine, Department of Physical Medicine and Rehabilitaton, Gaziantep University, Gaziantep, Türkiye, Turkey.
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2
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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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3
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Siegfried EC, Arkin LM, Chiu YE, Hebert AA, Callen JP, Castelo-Soccio L, Co DO, Cordoro KM, Curran ML, Dalrymple AM, Flohr C, Gordon KB, Hanna D, Irvine AD, Kim S, Kirkorian AY, Lara-Corrales I, Lindstrom J, Paller AS, Reyes M, Begolka WS, Tom WL, Van Voorhees AS, Vleugels RA, Lee LW, Davies OMT, Brandling-Bennett HA. Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines. Pediatr Dermatol 2023; 40:789-808. [PMID: 37316462 DOI: 10.1111/pde.15327] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/26/2023] [Indexed: 06/16/2023]
Abstract
Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication.
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Affiliation(s)
- Elaine C Siegfried
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lisa M Arkin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yvonne E Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adelaide A Hebert
- UTHealth McGovern Medical School at Houston, Houston, Texas, United States
| | - Jeffrey P Callen
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Leslie Castelo-Soccio
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic O Co
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Megan L Curran
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Austin M Dalrymple
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Carsten Flohr
- Department of Paediatric Dermatology, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ken B Gordon
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | - Susan Kim
- University of California, San Francisco, California, USA
| | - A Yasmine Kirkorian
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Children's National Hospital, Washington, DC, USA
| | | | - Jill Lindstrom
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melissa Reyes
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | | | - Wynnis L Tom
- University of California, San Diego School of Medicine, San Diego, California, USA
- Rady Children's Hospital-San Diego, San Diego, California, USA
| | | | - Ruth Ann Vleugels
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Wine Lee
- Medical University of South Carolina, Charleston, South Carolina, USA
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4
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Gao Y, Gao YN, Wang MJ, Zhang Y, Zhang FQ, He ZX, Chen W, Li HC, Xie ZJ, Wen CP. Efficacy and safety of tofacitinib combined with methotrexate in the treatment of rheumatoid arthritis: A systematic review and meta-analysis. Heliyon 2023; 9:e15839. [PMID: 37215854 PMCID: PMC10196519 DOI: 10.1016/j.heliyon.2023.e15839] [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] [Received: 12/27/2022] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
Objective To evaluate the efficacy and safety of tofacitinib in combination with methotrexate (MTX) versus MTX monotherapy in patients with active rheumatoid arthritis (RA). Methods Trials were identified from four electronic databases: PubMed, Web of science, Cochrane Library and EMBASE from inception to April 2022. Two independent reviewers evaluated each database to scan the title, abstract and keywords of each record retrieved. Full articles were further assessed when the information suggested that the study was a randomized clinical trial (RCT) comparing tofacitinib combined with MTX vs. MTX monotherapy in patients with active RA. Data were extracted from the literature, and the methodological quality of the included literature were evaluated and screened by two reviewers independently. The results were analyzed using RevMan5.3 software. The full text of the studies and extracted data were reviewed independently according to PRISMA guidelines. The outcome indicators were ACR 20, ACR 50, ACR 70, Disease activity score 28 (DAS28), erythrocyte sedimentation Rate (ESR) and adverse events (AEs). Results Of 1152 studies yielded by the search, 4 were retained, totaling 1782 patients (1345 treated with tofacitinib combined with MTX vs 437 received MTX. In the trial of insufficient response to MTX treatment, tofacitinib combined with MTX had significant advantages compared with MTX monotherapy. Numerically higher ACR20, ACR50 and ACR70 response rates were observed in the tofacitinib combined with MTX groups versus MTX monotherapy. ACR20 (odds ratio (OR), 3.62; 95% CI, 2.84-4.61; P < 0.001), ACR50 (OR, 5.17; 95% CI, 3.62-7.38; P < 0.001), and ACR70 (OR, 8.44; 95% CI, 4.34-16.41; P < 0.001), DAS28 (ESR) < 2.6 (OR, 4.71, 95% CI, 2.06-10.77; P < 0.001). The probability of adverse events of tofacitinib combined with MTX was lower than that of MTX monotherapy (OR, 1.42; 95% CI, 1.08-1.88; P = 0.01). The number of cases discontinued due to lack of efficacy or adverse events was similar in both groups (OR, 0.93; 95% CI, 0.52-1.68). The probability of abnormal liver enzymes in the treatment of tofacitinib combined with MTX was significantly lower than that of MTX monotherapy (OR, 1.86; 95% CI, 1.35-2.56). However, there was no significant difference between the two groups in severe adverse reactions, neutropenia, anemia and cardiovascular disease. Conclusions In terms of ACR20/50/70 and DAS28 (ESR), tofacitinib combined with MTX demonstrated superiority to MTX monotherapy in the treatment of patients with refractory RA. Considering the hepatoprotective and observably therapeutic efficacy, tofacitinib combined with MTX could be effective in treating refractory RA. However, in terms of hepatoprotective, it requires further large-scale and high-quality clinical trials to confirm.
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5
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Frikha O, Ben Salah R, Mefteh A, Frikha F, Snoussi M, Marzouk S, Bahloul Z. Agranulocytosis in systemic lupus erythematosus: A case report. Clin Case Rep 2022; 10:e6511. [DOI: 10.1002/ccr3.6511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/24/2022] [Accepted: 10/08/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Olfa Frikha
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Raida Ben Salah
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Ansar Mefteh
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Faten Frikha
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Mouna Snoussi
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Sameh Marzouk
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
| | - Zouhir Bahloul
- Department of Internal Medicine Hedi Chaker Hospital Sfax Tunisia
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6
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Liao T, Li M, Yuan T, Hong Q, Zeng Y, Yu D, Yu Q, Yu L, Pu T. Case Report: Severe thrombocytopenia induced by adalimumab in rheumatoid arthritis: A case report and literature review. Front Pharmacol 2022; 13:1041884. [DOI: 10.3389/fphar.2022.1041884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by persistent joint inflammation. In recent decades, biological agents such as anti-tumor necrosis factor-α (TNF-α) drugs have been applied in the treatment of RA and it achieved great improvement. The treatment has its side effects, but severe thrombocytopenia is very rare. In this case report we described the occurrence of severe thrombocytopenia in a patient with RA who was treated with adalimumab. Specially, the symptoms of the RA are not significantly improved by adalimumab treatment and severe thrombocytopenia it induced is resistant to treatment. After receiving four doses of adalimumab, the patient’s platelet count dropped to 4 × 103/μl. We halted adalimumab and administered glucocorticoids, interleukins, and platelet transfusion. On the sixth day, the platelet count rose to 52 × 103/μl. Lab tests and bone marrow pictures were unremarkable. Patient was treated with prednisone for maintenance. On day 17, the platelet count declined to 12 × 103/μl. We started the patient on methylprednisolone and recombinant human thrombopoietin (rh-TPO), but the effect was not significant. On day 25, intravenous immune globulin (IVIG) was applied in place of the rh-TPO. On 29th day, the patient’s platelets returned to normal. We summarized the existing literature on thrombocytopenia induced by anti-TNF-α drugs. This case suggested immunoglobulins could be considered for the treatment of refractory thrombocytopenia.
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7
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Sherbini AA, Gwinnutt JM, Hyrich KL, Verstappen SMM. Rates and predictors of methotrexate-related adverse events in patients with early rheumatoid arthritis: results from a nationwide UK study. Rheumatology (Oxford) 2022; 61:3930-3938. [PMID: 35078225 PMCID: PMC9536779 DOI: 10.1093/rheumatology/keab917] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To estimate prevalence rates and identify baseline predictors of adverse events (AEs) over the first year of treatment in patients with rheumatoid arthritis (RA) starting methotrexate (MTX). METHODS Data came from the UK Rheumatoid Arthritis Medication Study (RAMS), a prospective cohort of patients with RA starting MTX. This analysis included patients aged ≥ 18 years with physician diagnosed RA and symptom duration ≤ two years, who were commencing MTX for the first time. AEs were recorded by interviewing patients at six- and twelve-month follow-up visits. The period prevalence rates of AEs are reported for 0-6 months, 6-12 months, and 0-12 months of follow-up. The associations between baseline characteristics and AEs were assessed using multivariable logistic regression. RESULTS A total of 1069 patients were included in the analysis. Overall, 77.5% experienced at least one AE. The most commonly reported AEs were: gastrointestinal (42.0%), neurological (28.6%), mucocutaneous (26.0%), pulmonary (20.9%), elevated alanine transaminase (18.0%) and haematologic AEs (5.6%).Factors associated with increased odds of AEs were: women vs men (gastrointestinal, mucocutaneous, neurological), and alcohol consumption (nausea, alopecia, mucocutaneous). Older age, higher estimated Glomerular Filtration Rate (eGFR), and alcohol consumption were associated with less reporting of haematologic AEs. CONCLUSIONS AEs were common among patients over the first year of MTX, although most were not serious. Knowledge of the rates and factors associated with AEs occurrence are valuable when communicating risks prior to commencing MTX. This can help patients make informed decisions whether to start MTX, potentially increasing adherence to treatment.
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Affiliation(s)
- Ahmad A Sherbini
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK
| | - James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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8
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Bobircă A, Bobircă F, Ancuța I, Florescu A, Bojincă M, Muscă A, Florescu DN, Florescu LM, Sima RM, Florescu A, Mușetescu AE. COVID-19-A Trigger Factor for Severe Immune-Mediated Thrombocytopenia in Active Rheumatoid Arthritis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010077. [PMID: 35054471 PMCID: PMC8780601 DOI: 10.3390/life12010077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/13/2022]
Abstract
Thrombocytopenia is defined as a platelet count below 150,000/mm3 for adults. There is still controversy about whether individuals with platelet counts of 100,000/mm3 to 150,000/mm3 should be classified as having genuine thrombocytopenia or borderline thrombocytopenia. Thrombocytopenia is considered mild when the platelet count is between 70,000 and 150,000/mm3 and severe if the count is less than 20,000/mm3. Thrombocytopenia in rheumatoid arthritis is a rare complication, with an incidence estimated between 3 and 10%. The main etiological aspects include drug-induced thrombocytopenia and immune thrombocytopenic purpura. The most common hematological abnormalities in SARS-CoV-2 infection are lymphopenia and thrombocytopenia. It has been observed that the severity of thrombocytopenia correlates with the severity of the infection, being a poor prognosis indicator and a risk factor for mortality. COVID-19 can stimulate the immune system to destroy platelets by increasing the production of autoantibodies and immune complexes. Autoimmunity induced by viral infections can be related to molecular mimicry, cryptic antigen expression and also spreading of the epitope. During the COVID-19 pandemic, it is of great importance to include the SARS-CoV-2 infection in differential diagnoses, due to the increased variability in forms of presentation of this pathology. In this review, our aim is to present one of the most recently discovered causes of thrombocytopenia, which is the SARS-CoV-2 infection and the therapeutic challenges it poses in association with an autoimmune disease such as rheumatoid arthritis.
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Affiliation(s)
- Anca Bobircă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Florin Bobircă
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, 050474 Bucharest, Romania;
| | - Ioan Ancuța
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Anca Florescu
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Mihai Bojincă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Alice Muscă
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Bucur” Maternity, “Saint John” Clinical Emergency Hospital, 077160 Bucharest, Romania;
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Correspondence:
| | - Anca Emanuela Mușetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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9
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Agostini SBN, Malta IHS, Rodrigues RF, Freitas JTJ, Lino MEDS, Dos Santos RS, Elisei LS, Moraes TR, Giusto LADR, de Oliveira MK, Bassi da Silva J, Bruschi ML, Santos AMD, Nogueira DA, Novaes RD, Pereira GR, Galdino G, Carvalho FC. Preclinical evaluation of methotrexate-loaded polyelectrolyte complexes and thermosensitive hydrogels as treatment for rheumatoid arthritis. Eur J Pharm Sci 2021; 163:105856. [PMID: 33882329 DOI: 10.1016/j.ejps.2021.105856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/29/2022]
Abstract
This work proposes new methotrexate (MTX) loaded drug delivery systems (DDS) to treat rheumatoid arthritis via the intra-articular route: a poloxamer based thermosensitive hydrogel (MTX-HG), oligochitosan and hypromellose phthalate-based polyelectrolyte complexes (MTX-PEC) and their association (MTX-PEC-HG). MTX-PEC showed 470 ± 166 nm particle size, 0.298 ± 0.108 polydispersity index, +26 ± 2 mV and 74.3 ± 5.8% MTX efficiency entrapment and particle formation was confirmed by infrared spectroscopy and thermal analysis. MTX-HG and MTX-PEC-HG gelled at 36.7°C. MTX drug release profile was prolonged for MTX-HG and MTX-PEC-HG, and faster for MTX-PEC and free MTX. The in vivo effect of the MTX-DDSs systems was evaluated in induced arthritis rats as single intra-articular dose. The assessed parameters were the mechanical nociceptive threshold, the plasmatic IL-1β level and histological analysis of the tibiofemoral joint. MTX-HG and MTX-PEC-HG performance were similar to free MTX and worse than oral MTX, used as positive control. All DDSs showed some irritative effect, for which further studies are required. MTX-PEC was the best treatment on recovering cartilage damage and decreasing allodynia. Thus, MTX-PEC demonstrated potential to treat rheumatoid arthritis, with the possibility of decreasing the systemic exposure to the drug.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Merelym Ketterym de Oliveira
- Instituto de Ciências Biomédicas, Departamento de Ciências Fisiológicas, Universidade Federal de Alfenas, Brazil
| | - Jéssica Bassi da Silva
- Laboratório de Pesquisa e Desenvolvimento de Sistemas de Liberação de Fármacos, Departamento de Farmácia, Universidade Estadual de Maringá, Brazil
| | - Marcos Luciano Bruschi
- Laboratório de Pesquisa e Desenvolvimento de Sistemas de Liberação de Fármacos, Departamento de Farmácia, Universidade Estadual de Maringá, Brazil
| | - Aline Martins Dos Santos
- Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Julio de Mesquita Filho". UNESP, Araraquara, Brazil
| | | | - Rômulo Dias Novaes
- Instituto de Ciências Biomédicas, Departamento de Biologia Estrutural, Universidade Federal de Alfenas, Brazil
| | - Gislaine Ribeiro Pereira
- Escola de Farmácia, Departamento de Fármacos e Alimentos, Universidade Federal de Alfenas, Brazil
| | - Giovane Galdino
- Instituto de Ciência da Motricidade, Universidade Federal de Alfenas, Brazil
| | - Flávia Chiva Carvalho
- Escola de Farmácia, Departamento de Fármacos e Alimentos, Universidade Federal de Alfenas, Brazil
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10
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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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Kataoka H, Tomita T, Kondo M, Makita K, Tsuji T, Mukai M. Autopsy of a case of rheumatoid arthritis with severe bicytopoenia due to gelatinous transformation of the bone marrow. Mod Rheumatol Case Rep 2021; 5:236-240. [PMID: 33970059 DOI: 10.1080/24725625.2021.1913278] [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
We present the case of an elderly female patient with rheumatoid arthritis (RA) treated with methotrexate. She was referred to our hospital with severe malaise. She was emaciated and had massive pleural effusion that induced atelectasis. Her blood tests revealed elevated CRP, leukopenia, and severe anaemia. She lost consciousness on the third day of hospital stay and passed away the following day. Her autopsy showed gelatinous transformation of the bone marrow that gave rise to bicytopoenia, whereas there were no other causes for severe anaemia. Bone marrow gelatinous transformation can cause impaired haematopoiesis in elderly RA patients.
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Affiliation(s)
- Hiroshi Kataoka
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Hokkaido, Japan
| | - Tomoko Tomita
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Hokkaido, Japan
| | - Makoto Kondo
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Hokkaido, Japan
| | - Keishi Makita
- Department of Pathology, Sapporo City General Hospital, Hokkaido, Japan
| | - Takahiro Tsuji
- Department of Pathology, Sapporo City General Hospital, Hokkaido, Japan
| | - Masaya Mukai
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Hokkaido, Japan
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12
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Nakafero G, Grainge MJ, Card T, Mallen CD, Zhang W, Doherty M, Taal MW, Aithal GP, Abhishek A. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology (Oxford) 2021; 60:5785-5794. [PMID: 33725120 PMCID: PMC8645271 DOI: 10.1093/rheumatology/keab254] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/05/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives To examine incidence of treatment changes due to abnormal blood-test results and, to explore rates of treatment changes due to liver, kidney and haematological blood-test abnormalities in autoimmune rheumatic diseases (AIRD) treated with low-dose MTX or LEF. Methods Data for people with AIRDs prescribed MTX or LEF were extracted from the Clinical Practice Research Datalink. Participants were followed-up from first prescription of MTX or LEF in primary care. Primary outcome of interest was drug discontinuation, defined as a prescription gap of ≥90 days following an abnormal (or severely abnormal) blood-test result. Dose reduction was examined between consecutive prescriptions. Incidence rates per 1000 person-years were calculated. Results 15, 670 and 2,689 participants contributing 46, 571 and 4,558 person-years follow-up were included in MTX and LEF cohorts, respectively. The incidence of MTX and LEF discontinuation with abnormal (severely abnormal) blood-test was 42.24 (6.16) and 106.53 (9.42)/1000 person-years in year 1, and 22.44 (2.84) and 31.69 (4.40)/1000 person years, respectively, thereafter. The cumulative incidence of MTX and LEF discontinuation with abnormal (severely abnormal) blood tests was 1 in 24 (1 in 169), 1 in 9 (1 in 106) at 1 year; and 1 in 45 (1 in 352), 1 in 32 (1 in 227) per-year, respectively, thereafter. Raised liver enzymes were the commonest abnormality associated with drug discontinuation. MTX and LEF dose reduction incidence were comparable in year 1, however, thereafter MTX dose was reduced more often than LEF [16.60 (95% CI 13.05, 21.13) vs 8.10 (95% CI 4.97, 13.20)/1000 person-years]. Conclusion MTX and LEF were discontinued for blood-test abnormalities after year 1 of treatment, however, discontinuations for severely abnormal results were uncommon.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Grainge
- Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele
| | - Weiya Zhang
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Maarten W Taal
- Division of Medical Sciences and Graduate Entry Medicine, University on Nottingham
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham.,NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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13
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Nikas SN. 2020 Clinical Highlights in Rheumatology. Mediterr J Rheumatol 2021; 31:421-423. [PMID: 33521576 PMCID: PMC7841090 DOI: 10.31138/mjr.31.4.421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/04/2022] Open
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14
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Vanni KMM, Berliner N, Paynter NP, Glynn RJ, MacFadyen J, Colls J, Lu F, Xu C, Ridker PM, Solomon DH. Adverse Effects of Low-Dose Methotrexate in a Randomized Double-Blind Placebo-Controlled Trial: Adjudicated Hematologic and Skin Cancer Outcomes in the Cardiovascular Inflammation Reduction Trial. ACR Open Rheumatol 2020; 2:697-704. [PMID: 33201596 PMCID: PMC7738806 DOI: 10.1002/acr2.11187] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Objective Low‐dose methotrexate (LD‐MTX), a cornerstone in the treatment of rheumatoid arthritis, is associated with a moderately increased risk of anemia, leukopenia, and skin cancers, but the risks of myelosuppression and malignancy during LD‐MTX use remain incompletely described. We examined the risks of cytopenias and skin cancers among patients taking LD‐MTX versus placebo in a large randomized controlled trial (RCT). Methods We prespecified secondary analyses of a double‐blind, placebo‐controlled RCT that included adults with known cardiovascular disease and diabetes or metabolic syndrome in the United States and Canada. Subjects were randomly allocated to LD‐MTX (20 mg/week maximum) or placebo. All subjects received folic acid (1 mg daily for 6days/week). We assessed the frequency of blindly adjudicated hematologic and malignant adverse events (AEs). Results A total of 2391 subjects were randomized to LD‐MTX (mean dosage 14.9 mg/week), and 2395 were randomized to placebo. During follow‐up, in the LD‐MTX arm, simultaneous two‐line cytopenias (n = 92 [3.9%]) or pancytopenia (n = 13 [0.54%]) were infrequent. Pancytopenia developed as soon as 4 months and as late as 3.5 years after beginning LD‐MTX, though the latter subject had been recently diagnosed with multiple myeloma. Overall skin cancer risk was increased in users of LD‐MTX compared with users of placebo, which driven largely by a statistically significant increased risk of squamous cell skin cancer (hazard ratio [HR] 3.31; 95% confidence interval [CI] 1.63‐6.71). Melanoma was increased in LD‐MTX, but this was not statistically significant (HR 2.33; 95% CI 0.60‐9.01). Conclusions Among subjects using LD‐MTX, simultaneous two‐line cytopenias and pancytopenia were uncommon. We found more cases of skin cancer, particularly squamous cell carcinomas, in the LD‐MTX arm than the placebo arm.
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Affiliation(s)
| | | | | | | | | | - Joshua Colls
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Fengxin Lu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Chang Xu
- Brigham and Women's Hospital, Boston, Massachusetts
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15
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Vanni KMM, Solomon DH. Comment on: Cytopenias among patients with rheumatic diseases using methotrexate: a meta-analysis of randomized controlled clinical trials: reply. Rheumatology (Oxford) 2020; 59:e76. [PMID: 32705125 DOI: 10.1093/rheumatology/keaa290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/30/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Daniel H Solomon
- Division of Rheumatology.,Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA
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Murray KE, Turk MA, Veale DJ. Comment on: Cytopenias among patients with rheumatic diseases using methotrexate: a meta-analysis of randomized controlled clinical trials. Rheumatology (Oxford) 2020; 59:e74-e75. [PMID: 32705141 DOI: 10.1093/rheumatology/keaa286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kieran E Murray
- Department of Rheumatology, Saint Vincent's University Hospital.,EULAR Centre For Arthritis and Rheumatic Diseases, Dublin Academic Medical Centre, Dublin 4, Ireland
| | - Matthew A Turk
- Department of Rheumatology, Saint Vincent's University Hospital.,EULAR Centre For Arthritis and Rheumatic Diseases, Dublin Academic Medical Centre, Dublin 4, Ireland
| | - Douglas J Veale
- Department of Rheumatology, Saint Vincent's University Hospital.,EULAR Centre For Arthritis and Rheumatic Diseases, Dublin Academic Medical Centre, Dublin 4, Ireland
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