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Wibrand C, Kyvsgaard N, Herlin T, Glerup M. Methotrexate Intolerance in Juvenile Idiopathic Arthritis: Definition, Risks, and Management. Paediatr Drugs 2024:10.1007/s40272-024-00643-9. [PMID: 39044097 DOI: 10.1007/s40272-024-00643-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/25/2024]
Abstract
Juvenile idiopathic arthritis is the most common rheumatic disorder in childhood and adolescence posing a significant threat of short-term and long-term disability if left untreated. Methotrexate is a folic acid analog with various immunomodulatory properties. It has demonstrated significant efficacy for the treatment of juvenile idiopathic arthritis, often considered the preferred first-line disease-modifying anti-rheumatic drug given as monotherapy or in combination with biological drugs. Despite this, there is a considerable risk for treatment disruptions owing to the high prevalence of methotrexate intolerance, with symptoms such as nausea, stomach ache, vomiting, and behavioral symptoms. Many different risk factors for the intolerance have been proposed including gender, age, disease activity, treatment duration, dosing and administration, and genetic and psychological factors. As the studies have shown contradictory results, many questions are left unanswered. Therefore, a consensus regarding outcome measures and reporting is crucial. In this review, we describe the identification and assessment of methotrexate intolerance and evaluate potential risk factors, genetic associations as well as management strategies.
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Affiliation(s)
- Camilla Wibrand
- Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Nini Kyvsgaard
- Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Herlin
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Mia Glerup
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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Kanda M, Sato M, Nagahata K, Naishiro Y, Murakami R, Honda S, Suzuki C. Assessment of oral methotrexate intolerance in Japanese adult patients with rheumatoid arthritis. Int J Rheum Dis 2024; 27:e15029. [PMID: 38287557 DOI: 10.1111/1756-185x.15029] [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: 05/30/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/31/2024]
Abstract
AIM The objective of this study was to assess the gastrointestinal side (GI) effects of oral methotrexate (MTX) in Japanese adult patients with rheumatoid arthritis (RA). METHODS In this single-center retrospective study, 112 Japanese adult patients (over 18 years old) with RA were examined by Methotrexate Intolerance and Severity assessment in Adults (MISA) questionnaire. RESULTS Forty-five (40.2%) of patients were MTX intolerant (MISA score ≥1). Twelve patients (11.2%) were moderate-to-severe MTX intolerant (MISA cross-product score ≥4). The most common GI side effects of MTX were gastric discomfort (26.8%), followed by loss of appetite or dysgeusia (14.3%), fatigue and lethargy (12.5%), and nausea (10.7%). CONCLUSIONS Japanese adult patients with RA showed a high prevalence of MTX intolerance even in low-dose oral MTX. The MISA questionnaire was practical for finding patients with MTX intolerance.
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Affiliation(s)
- Masatoshi Kanda
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Mayumi Sato
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
| | - Ken Nagahata
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | - Rieko Murakami
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
| | - Saho Honda
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
| | - Chisako Suzuki
- Department of Rheumatology, JR Sapporo Hospital, Sapporo, Japan
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Dhir V, Prasad CB, Kumar S, Kaul KK, Dung N, Naidu GSRSNK, Sharma SK, Sharma A, Jain S. Long-term persistence of oral methotrexate and associated factors in rheumatoid arthritis: a retrospective cohort study. Rheumatol Int 2023; 43:867-873. [PMID: 36933068 DOI: 10.1007/s00296-023-05305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
There is little data on long-term persistence/continuation of methotrexate among Indian Rheumatoid arthritis patients. We assembled a retrospective single-center cohort consisting of RA patients (fulfilling 1987 ACR criteria) started on methotrexate as part of three academic studies (including two RCTs) from 2011 to 2016. Oral methotrexate was started at 7.5 or 15 mg per week with a target dose of 25 mg per week. Between August and December 2020, all patients were contacted (telephonically) and data were obtained from clinic files to evaluate self-reported continuation/persistence of methotrexate and reasons for discontinuation. Survival analysis using Kaplan-Meier and cox-regression were used to assess methotrexate continuation rates and factors associated with its discontinuation. This study included 317 patients with rheumatoid arthritis, with mean age and disease duration (at enrollment) of 43 years and 2 years; And positive rheumatoid factor and anti-CCP in 69 and 75%. At follow-up, 16 patients (5%) had died, whereas 103 (32.5%) had discontinued methotrexate. On Kaplan-Meier survival analysis, the mean survival (continuation) time for methotrexate was 7.3 years (95% CI 7-7.6 years). The actuarial continuation/persistence of methotrexate at 3, 5 and 9 years was 92, 81 and 51%, respectively. Among those who discontinued methotrexate, common reasons were remission of disease, symptomatic adverse effects (intolerance), perceived lack of efficacy and socioeconomic reasons. On multivariable cox-regression, symptomatic adverse effects during the first 12-24 weeks (Hazard ratio, 95% CI 1.8 (1.2-2.8)) and anti-CCP positivity (Hazard ratio, 95% CI 0.6 (0.3-1.0)) were significantly associated with hazard of discontinuation. Persistence or continuation of methotrexate was found to be good and comparable to reports in other centers world-wide. Apart from remission, the most important cause of methotrexate discontinuation was symptomatic adverse effects (intolerance).
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Affiliation(s)
- Varun Dhir
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Chandra Bhushan Prasad
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sandeep Kumar
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kavya Kriti Kaul
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Neha Dung
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - G S R S N K Naidu
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali K Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Leon L, Madrid-Garcia A, Lopez-Viejo P, González-Álvaro I, Novella-Navarro M, Freites Nuñez D, Rosales Z, Fernandez-Gutierrez B, Abasolo L. Difficult-to-treat rheumatoid arthritis (D2T RA): clinical issues at early stages of disease. RMD Open 2023; 9:rmdopen-2022-002842. [PMID: 36889800 PMCID: PMC10008455 DOI: 10.1136/rmdopen-2022-002842] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVES Most studies on difficult-to-treat rheumatoid arthritis (D2T RA) have focused on established RA. Here, we analyse whether disease activity in the early stages of RA could influence progression to a D2T RA under real-life conditions. Other clinical and treatment-related factors were also analysed. METHODS A longitudinal multicentre study of patients with RA was conducted from 2009 to 2018. Patients were followed up until January 2021. D2T RA was defined based on EULAR criteria (treatment failure, signs suggestive of currently active/progressive disease and management being perceived as problematic by the rheumatologist and/or patient). The main variable was disease activity in the early stages. The covariates were sociodemographic, clinical and treatment-related factors. We ran a multivariable logistic regression analysis to investigate risk factors associated with progression to D2T RA. RESULTS The study population comprised 631 patients and 35 (5.87%) developed D2T RA. At the time of diagnosis, the D2T RA group were younger, with a higher disability, 28-joint Disease Activity Score (DAS28) score, tender joint count and pain scores. In our final model, DAS28 was not statistically significantly associated with D2T RA. No differences were found between groups for therapy. Disability was independently associated with D2T RA (OR: 1.89; p=0.01). CONCLUSIONS In this cohort of patients newly diagnosed with RA, our results do not allow us to prove the influence of active disease according to DAS28. However, we did find that younger patients and those with elevated initial disability scores are more likely to develop D2T RA regardless of other factors.
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Affiliation(s)
- Leticia Leon
- IdISSC and Rheumatology, Hospital Clinico Universitario San Carlos, Madrid, Spain .,Health Sciences, Universidad Camilo Jose Cela, Villafranca del Castillo, Spain
| | | | | | | | | | | | - Zulema Rosales
- Rheumatology, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | | | - Lydia Abasolo
- IdISSC and Rheumatology, Hospital Clinico Universitario San Carlos, Madrid, Spain
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