British Association of Dermatologists' guidelines for the safe and effective prescribing of methotrexate for skin disease 2016

Systematic review: Methotrexate-A poorly understood and underused medication in inflammatory bowel disease

BACKGROUND

Methotrexate, an immunosuppressant used for the treatment of inflammatory bowel disease (IBD) for over 30 years, remains underused compared to thiopurines.

AIMS

To review the efficacy, safety, optimal dosing and delivery regimens of methotrexate in adults with IBD.

METHODS

We conducted a systematic review of studies involving patients with IBD treated with methotrexate from inception to August 2023. All studies were included from the MEDLINE database via PubMed.

RESULTS

For Crohn's disease, we included eight randomised controlled trials (RCTs) and 17 observational studies. Parenteral methotrexate effectively increased remission rates in steroid-dependent patients at 25 mg/week for 16 weeks and at 15 mg/week for maintenance. Methotrexate can be used in combination with anti-tumour necrosis factor (TNF) agents to reduce immunogenicity. Data comparing thiopurines and methotrexate remain scarce. For ulcerative colitis (UC), we included five RCTs and 10 observational studies were included; there was no evidence to support the use of methotrexate in (UC). We extracted safety data from 17 studies; mild-to-moderate adverse effects were common. The incidence of liver fibrosis or cirrhosis was low.

CONCLUSION

Methotrexate is effective at inducing and maintaining remission in steroid-refractory Crohn's disease and can reduce anti-TNF-induced immunogenicity when used in combination therapy. Data regarding tolerance and safety are reassuring. These findings challenge preconceived ideas on methotrexate and suggest that it is a valid first-line conventional option for the treatment of mild-to-moderate Crohn's disease.

Bimekizumab safety in moderate to severe plaque psoriasis: Rates of hepatic events and changes in liver parameters over 2 years in randomized phase 3/3b trials

BACKGROUND

Patients with psoriasis are at increased risk of liver function abnormalities.

OBJECTIVE

Explore rates of hepatic treatment-emergent adverse events (TEAEs) and changes in liver parameters in bimekizumab-treated patients with psoriasis.

METHODS

Data are reported from 5 phase 3/3b trials over 2 years. Hepatic TEAEs, laboratory elevations in alanine aminotransferase (ALT) or aspartate aminotransferase (AST), and changes in clinical markers of liver fibrosis (Fibrosis-4 [FIB-4] Index and AST to Platelet Ratio Index [APRI]) are reported. TEAEs are presented using exposure-adjusted incidence rates (EAIRs) per 100 patient-years (PY).

RESULTS

2186 patients received ≥1 bimekizumab dose. Over 2 years, the EAIR of hepatic TEAEs was 3.5/100 PY and did not increase from first to second year. 2-year EAIRs of ALT/AST elevations >3x and >5x the upper limit of normal were 2.3 and 0.6/100 PY; rates were similar to placebo, adalimumab, secukinumab, and ustekinumab during controlled study periods. FIB-4 and APRI scores did not increase through 2 years, regardless of fibrosis risk at baseline.

LIMITATIONS

Obesity, diabetes, dyslipidemia, chronic alcohol consumption, and medication changes are confounding factors for hepatic dysfunction.

CONCLUSION

Rates of hepatic adverse events (AEs) with bimekizumab were consistent through 2 years; incidences of transaminase elevations were similar to comparators during phase 3/3b controlled study periods.

Basic Susceptibility of Patients with Psoriasis under Systemic Therapy for Respiratory Infections: Data from the German Psoriasis Registry PsoBest

Background: Patients with psoriasis under systemic treatments are in focus regarding their susceptibility to respiratory infections. To analyse real-world data for respiratory infections in patients with psoriasis under systemic treatments. Methods: We analysed data of the prospective, non-interventional German Psoriasis Registry PsoBest and compared rates for respiratory infections of 13,823 patients on systemic treatments for psoriasis and/or psoriatic arthritis in different therapy cohorts before the COVID-19 pandemic. Results: In total, 1415 respiratory infections were observed in 970 patients. Significant differences were observed between biologics and non-biologics, but not within these groups. The highest event rates (events/100 patient years) were identified for TNF-α inhibitors, 8.1, (CI 7.4-8.9), followed by 7.0 for IL-17 inhibitors (6.2-7.9), 5.7 for IL-12/23 and IL-23 inhibitors (5.1-6.5), 4.8 for methotrexate (4.3-5.4), 3.7 for small molecules (3.3-4.2), and 2.7 for retinoids (1.2-5.1). Conclusions: Overall, the susceptibility for respiratory infections in patients under systemic therapy for psoriasis is low compared to published study data and is sufficient as comparative data for COVID-19 studies.

Pneumocystis jirovecii pneumonia in non-HIV patients: need for a more extended prophylaxis

Background

Pneumocystis jirovecii pneumonia (PCP) has a significant mortality rate for non-HIV immunocompromised patients. Prevention is primarily based on combined trimethoprim and sulfamethoxazole (TMP-SMX) but guidelines on pneumocystosis prophylaxis are scattered and not consensual.

Objectives

This study aims to describe PCP in non-HIV patients and to review case by case the prior indication of prophylaxis according to specific guidelines.We included patients with confirmed diagnosis of PCP admitted to one university hospital from 2007 to 2020. Prior indication for pneumocystis prophylaxis was assessed according to the specific guidelines for the underlying pathology or treatment.

Results

Of 150 patients with a medical diagnosis of PCP, 78 were included. Four groups of underlying pathologies were identified: hematological pathologies (42%), autoimmune diseases (27%), organ transplantation (17%), and other pathologies at risk of PCP (14%). A small subgroup of 14 patients (18%) had received a prior prescription of pneumocystis prophylaxis but none at the time of the episode. Transfer to intensive care was necessary for 33 (42%) patients, and the mortality rate at 3 months was 20%. According to international disease society guidelines, 52 patients (59%) should have been on prophylaxis at the time of the pneumocystis episode. Lowest compliance with guidelines was observed in the hematological disease group for 24 patients (72%) without prescription of indicated prophylaxis.

Conclusion

Infectious disease specialists should draw up specific prophylactic guidelines against pneumocystis to promote a better prevention of the disease and include additional criteria in their recommendations according to individual characteristics to prevent fatal cases.

An Overview of Methotrexate Indications in Skin Diseases

Methotrexate is an immunosuppressive drug with remarkable therapeutic results in the treatment of autoimmune and proliferative skin diseases. Although it has been more than half a century since it was first introduced into the therapeutic arsenal of dermatologists, there are currently no standardized therapeutic protocols regarding the prescription of methotrexate in dermatology, with the exception of psoriasis treatment. This review aims to highlight the indications and benefits of methotrexate beyond psoriasis, with a focus on a wide range of inflammatory, vesiculobullous, and proliferative dermatological pathologies.

Management of Psoriasis Patients with Serious Infectious Diseases

The management of patients affected by moderate-to-severe psoriasis may be challenging, in particular in patients with serious infectious diseases [tuberculosis (TB), hepatitis B and C, HIV, COVID-19]. Indeed, these infections should be ruled out before starting and during systemic treatment for psoriasis. Currently, four conventional systemic drugs (methotrexate, dimethyl fumarate, acitretin, cyclosporine), four classes of biologics (anti-tumour necrosis factor alpha, anti-interleukin (IL)12/23, anti-IL-17s, and anti-IL-23], and two oral small molecules (apremilast, deucravacitinib) have been licensed for the treatment of moderate-to-severe psoriasis. Each of these drugs is characterized by a unique safety profile which should be considered before starting therapy. Indeed, some comorbidities or risk factors may limit their use. In this context, the aim of this manuscript was to evaluate the management of patients affected by moderate-to-severe psoriasis with serious infectious diseases.

Analysis of factors influencing target PASI responses and side effects of methotrexate monotherapy in plaque psoriasis: a multicenter study of 1521 patients

Methotrexate (MTX) is commonly used as first-line systemic treatment agent in psoriasis. We aimed to evaluate the clinical characteristics and treatment responses of patients with psoriasis undergoing MTX monotherapy. Data from adult patients with plaque psoriasis who received MTX monotherapy for at least 3 months between April 2012 and April 2022 were retrospectively evaluated in 19 tertiary care centers. Our study included 722 female and 799 male patients, a total of 1521 participants. The average age of the patients was 44.3 ± 15.5 years. Mode of treatment was oral in 20.4% of patients while in 79.4% it was subcutaneous. The median treatment duration was 8 months (IQR = 5-15). The median weekly dose was 15 mg (IQR = 11-15). 1448 (95.2%) patients were taking folic acid supplementation. At week 12, 16.3% of the patients achieved PASI (Psoriasis Area and Severity Index) 90 response while at week 24, 37.3% achieved it. Logistic regression analysis for week 12 identified the following independent factors affecting PASI 90 achievement positively: median weekly MTX dose ≤ 15 mg (P = 0.011), subcutaneous administration (P = 0.005), no prior systemic treatment (< 0.001) and folic acid use (0.021). In logistic regression analysis for week 24; median weekly MTX dose ≤ 15 mg (P = 0.001), baseline PASI ≥ 10 (P < 0.001), no prior systemic treatment (P < 0.004), folic acid use (P = 0.001) and absence of comorbidities (P = 0.009) were determined as independent factors affecting the achievement of PASI 90. Adverse effects were observed in 38.8% of the patients, with nausea/vomiting (23.9%) and transaminase elevation (13%) being the most common. The most common reasons for interruptions (15.3%) and discontinuations (27.1%) of the treatment were patient related individual factors. The use of MTX as the first systemic treatment agent, at doses ≤ 15 mg/week and concurrent folic acid application are positive predictive factors for achieving the target PASI response both at weeks 12 and 24. In our study, which is one of the most comprehensive studies on MTX treatment in psoriasis, we observed that MTX is an effective and safe treatment option.

Antiproliferative and Anti-Inflammatory Effects of the Polyphenols Phloretin and Balsacone C in a Coculture of T Cells and Psoriatic Keratinocytes

Plaque psoriasis is a chronic inflammatory skin disease causing red inflamed lesions covered by scales. Leukocytes, including dendritic cells and T cells, participate in the inflammation of the skin by producing multiple cytokines, thus contributing to the hyperproliferation of keratinocytes. Lack of effectiveness and toxic side effects are the main concerns with conventional treatments, and research involving new antipsoriatic molecules is essential. In this study, the anti-inflammatory and antiproliferative effects of two natural polyphenols, phloretin and balsacone C, were investigated using the coculture of T cells and psoriatic keratinocytes. Phloretin exerted antiproliferative activity by regulating the expression of antigen Ki67 and proliferating cell nuclear antigen (PCNA). These effects were comparable to those of methotrexate, a reference treatment for moderate to severe psoriasis. With balsacone C, the expression of Ki67 was also reduced. Additionally, phloretin decreased the levels of multiple pro-inflammatory cytokines: monocyte chemoattractant protein-1 (MCP-1/CCL2), macrophage inflammatory protein-1α (MIP-1α), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-1 alpha (IL-1α), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), interleukin-17A (IL-17A), and tumor necrosis factor alpha (TNF-α). The increased interleukin-2 (IL-2) levels with phloretin and methotrexate also represented anti-inflammatory activity. Balsacone C and methotrexate decreased the levels of IL-1α and IL-1β, but methotrexate exerted a higher reduction. In summary, the anti-inflammatory effects of phloretin were more pronounced than those of methotrexate and balsacone C. In addition, the expression of lymphocyte common antigen (CD45) was more similar to that of the healthy condition after using phloretin or methotrexate. Finally, phloretin stood out from the other compounds and appears promising for psoriasis treatment.

Treatment of Refractory Vulvar Lichen Sclerosus With Methotrexate

We report the successful treatment of severe vulvar lichen sclerosus refractory to topical corticosteroids in 3 adult female patients using low-dose oral methotrexate. All cases reported symptomatic and clinical improvement within 12 weeks.

Methotrexate therapy for adult and paediatric moderate-to-severe atopic dermatitis: A PRISMA-compliant meta-analysis of data from daily practice

Of the 15 eligible studies identified via electronic searches in MEDLINE, EMBASE and CENTRAL in November 2022 for methotrexate therapy of moderate-to-severe atopic dermatitis, 12 were non-randomized controlled trial (non-RCT) studies with data from 437 patients (235 adults and 202 children). The response rates for short-term therapy were 77% [95% CI 55-99] (four studies; adults) - comparable to 81% [54-100] of RCTs (two studies; adults) (p = 0.63) - and 61% [43-79] (two studies; children), and for medium/long-term therapy were 88.9% [74.3-100.0] (four studies; adults) and 77.7% [61.5-94.0] (three studies; children). Children had a markedly lower rate of treatment discontinuation due to side effects [2.0% (five studies; children) vs. 14.9% (six studies; adults)], but were more likely to experience gastrointestinal disorders {relative risk (RR) 2.0 [1.44-2.71]}, fatigue (RR 2.3 [1.35-3.72]), headache (RR 2.8 [1.23-5.61]), and infections (RR 2.9 [2.18-3.58]). Other adverse events (children vs. adults) included hepatic disorders (32/176 vs. 35/305) and blood and lymphatic system/bone marrow disorders (25/148 vs. 19/184). Four serious adverse events were reported (children). Evidence from daily practice was limited by bias in the selection of participants in the study.

Longitudinal assessment of liver stiffness using ARFI technique does not support increased risk of fibrosis in rheumatoid arthritis patients on methotrexate

AIMS

To assess the liver stiffness in patients with rheumatoid arthritis treated with methotrexate monotherapy using non-invasive, ultrasound-based elastography (acoustic radiation force impulse (ARFI) imaging) in a longitudinal approach.

METHODS

In total, 23 MTX-naive patients were longitudinally assessed using acoustic radiation force impulse (ARFI) imaging. Baseline assessments were carried out between July 2018 and April 2019, and the follow-up evaluations took place after an average of 2.6 years. The main outcome variable was the mean shear wave velocity as measured by the ARFI method. It was calculated from 10 valid ARFI measurements for each patient. Inferential statistical analyses (within-group comparisons) were performed using t-tests for dependent samples or suitable nonparametric procedures.

RESULTS

The main finding was that observed ARFI shear wave velocities did not increase during the observation period. In fact, this parameter decreased over time from 1.07 m/s (SD = 0.23) at baseline without MTX exposure to 0.97 m/s (SD = 0.16) at follow-up after a mean of 2.6 years (P = 0.013). Moreover, the magnitude of the change in shear wave velocity could not be predicted by indicators of inflammation or disease activity, BMI, age, sex or NSAR intake (corresponding regression analysis: corrected R2 = 0.344; P = 0.296).

CONCLUSIONS

No increased risk of liver fibrosis was found in RA patients treated with MTX monotherapy during observation period.

Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature

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.

Update on the systemic management of noninfectious uveitis in children and adolescents

Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.

Current issues with procollagen III N-terminal peptide assay performance relevant to 2016 British Association for Dermatologist methotrexate-monitoring guidance

Procollagen III N-terminal peptide (P3NP) testing is routinely used to detect possible liver fibrosis according to the cutoffs in the British Association of Dermatologists (BAD) 2016 guidelines for the safe and effective prescribing of methotrexate in skin disease. We report significant changes to P3NP test performance that will potentially change patient management according to the BAD 2016 guidelines.

Screening for hepatic fibrosis in patients with psoriasis prescribed methotrexate: can we make a change?

The aim of this study was to assess whether correlation existed between procollagen III N-terminal peptide levels, used for monitoring for hepatic fibrosis in patients with psoriasis prescribed methotrexate, and other screening tools (Fibrosis-4 score) and then resultant FibroScan®, with the aim of potentially altering current clinical practice. The retrospective analysis highlighted how both screening tools, if used, can prompt onward referral for FibroScan; however, the small sample size limited statistical conclusions. Nevertheless, we feel this observational study can help guide future investigation into potential changes to hepatic fibrosis monitoring for this cohort.

Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus

BACKGROUND

After decades of use, methotrexate displays an established safety and efficacy profile in both in-hospital and outpatient settings. Despite its widespread use, there is surprisingly little clinical evidence to guide daily practice with methotrexate in dermatology.

OBJECTIVES

To provide guidance for clinicians in daily practice for areas in which there is limited guidance.

METHODS

A Delphi consensus exercise on 23 statements was carried out on the use of methotrexate in dermatological routine settings.

RESULTS

Consensus was reached on statements that cover six main areas: (1) pre-screening exams and monitoring of therapy; (2) dosing and administration in patients naïve to methotrexate; (3) optimal strategy for patients in remission; (4) use of folic acid; (5) safety; and (6) predictors of toxicity and efficacy. Specific recommendations are provided for all 23 statements.

CONCLUSIONS

In order to optimize methotrexate efficacy, it is essential to optimize treatment using appropriate dosages, carrying out a rapid drug-based step-up on a treat-to-target strategy and preferably using the subcutaneous formulation. To manage safety aspects appropriately, it is essential to evaluate patients' risk factors and carry out proper monitoring during the course of treatment.

Prescribing for pregnancy: chronic skin diseases

Chronic skin disease is common in women of reproductive age. Although skin can improve or remain stable during pregnancy, it is also common for existing conditions to flare and for new conditions to develop. A small number of medications used to control chronic skin disease can potentially have adverse effects on the outcome of the pregnancy. This article forms part of a series on prescribing for pregnancy and highlights the importance of achieving good control of the skin disease prior to conception and during pregnancy. It emphasises the need for patient-centred, open and informed discussions around medication options to achieve good control. During pregnancy and breastfeeding each patient should be treated as an individual in accordance with the medications that are appropriate for them, their preferences, and the severity of their skin disease. This should be done through collaborative working across primary care, dermatology and obstetric services.

Busting the myth of methotrexate chronic hepatotoxicity

Methotrexate is a key component of the treatment of inflammatory rheumatic diseases and the mainstay of therapy in rheumatoid arthritis. Hepatotoxicity has long been a concern for prescribers envisaging long-term treatment with methotrexate for their patients. However, the putative liver toxicity of methotrexate should be evaluated in the context of advances in our knowledge of the pathogenesis and natural history of liver disease, especially non-alcoholic fatty liver disease (NAFLD). Notably, patients with NAFLD are at increased risk for methotrexate hepatotoxicity, and methotrexate can worsen the course of NAFLD. Understanding the mechanisms of acute hepatotoxicity can facilitate the interpretation of elevated concentrations of liver enzymes in this context. Liver fibrosis and the mechanisms of fibrogenesis also need to be considered in relation to chronic exposure to methotrexate. A number of non-invasive tests for liver fibrosis are available for use in patients with rheumatic disease, in addition to liver biopsy, which can be appropriate for particular individuals. On the basis of the available evidence, practical suggestions for pretreatment screening and long-term monitoring of methotrexate therapy can be made for patients who have (or are at risk for) chronic liver disease.

Risk of liver fibrosis associated with long-term methotrexate therapy may be overestimated

BACKGROUND & AIMS

The risk of significant liver fibrosis from prolonged methotrexate (MTX) exposure has been estimated at around 5%, prompting intensive monitoring strategies. However, the evidence is derived from retrospective studies that under-reported risk factors for liver disease. We evaluated the risk of long-term MTX therapy on liver fibrosis in a longitudinal cohort study using two non-invasive markers.

METHOD

Between 2014-2021, adult patients diagnosed with rheumatoid arthritis (RA) or psoriasis for ≥2 years were recruited prospectively from six UK sites. The MTX group included patients who received MTX for ≥6 months, whereas the unexposed group included those who never received MTX. All patients underwent full liver profiling, with transient elastography (TE) and enhanced liver fibrosis (ELF) marker measurements.

RESULTS

A total of 999 patients (mean age 60.8 ± 12 years, 62.3% females) were included. Of 976 with valid TE values, 149 (15.3%) had liver stiffness ≥7.9 kPa. Of 892 with a valid ELF, 262 (29.4%) had ELF ≥9.8. Age and BMI were independently associated with elevated liver stiffness and ELF. Neither MTX cumulative dose nor duration was associated with elevated liver stiffness. Diabetes was the most significant risk factor associated with liver stiffness ≥7.9 kPa (adjusted odds ratio = 3.19; 95% CI 1.95-5.20; p <0.001). Regular use of non-steroidal anti-inflammatory drugs showed the strongest association with ELF ≥9.8 (odds ratio = 1.76; 95% CI 1.20-2.56; p = 0.003), suggesting the degree of joint inflammation in RA may confound ELF as a non-invasive marker of liver fibrosis.

CONCLUSION

The risk of liver fibrosis attributed to MTX itself might have been previously overestimated; there is a need to consider modifying current monitoring guidelines for MTX.

IMPACT AND IMPLICATIONS

Current guidelines recommend intensive (2-3 monthly) monitoring strategies for patients on long-term methotrexate therapy due to the potential risk of liver fibrosis. Evaluation of the association using two validated non-invasive markers of liver fibrosis, liver stiffness and enhanced liver fibrosis score, in a large cohort of patients with rheumatoid arthritis or psoriasis shows that the reported risk has previously been overestimated. The clinical focus should be to improve patients' metabolic risk factors, diabetes and BMI, that are independently associated with liver stiffness. There is a need to consider modifying current treatment monitoring guidelines for methotrexate.

Fatal low-dose methotrexate toxicity: A case report and literature review

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.

Methotrexate Dosing Regimen for Plaque-type Psoriasis: An Update of a Systematic Review

Background Methotrexate (MTX) is a systemic treatment for plaque-type psoriasis. At the time of approval, no dose-ranging studies were performed. Nowadays, a uniform dosing regimen is lacking. This might contribute to suboptimal treatment with the drug.Objective To summarize the literature involving the MTX dosing regimens in psoriasis patients.Methods In this SR, RCTs and documents with aggregated evidence (AgEv) on the MTX dosing regimen in psoriasis were summarized. All randomized controlled trials (RCTs) in which oral, subcutaneous or intramuscular MTX was used in patients with psoriasis and AgEv, were included. The MEDLINE, EMBASE and CENTRAL databases were searched up to June 20, 2022. This SR was registered in PROSPERO.Results Thirty-nine RCTs had a high risk of bias. Test dosages were given in only 3 RCTs. In the RCTs, MTX was usually prescribed in a start dose of 7.5 mg/week (n = 13). MTX was mostly given in a start dose of 15 mg/week, in the AgEv (n = 5). One guideline recommended a test dose, in other aggregated evidence a test dose was not mentioned or even discouraged.Conclusions There is a lack of high-quality evidence and available data for dosing MTX in psoriasis is heterogeneous.

National quality improvement intervention to reduce high risk oral methotrexate prescribing

Background

Harmful or fatal errors related to accidental overdose of methotrexate tablets are well documented. In England, the coprescription of 2.5 mg and 10 mg methotrexate tablets is not recommended, because both tablets look similar, and may be confused with each other, leading to a potential overdose of methotrexate. It is recommended that one tablet strength (usually 2.5 mg) is prescribed and dispensed. A recent retrospective cohort study identified that while 97% of patients in England were prescribed only 2.5 mg methotrexate tablets, the prescribing of 10 mg tablets or combinations of 2.5 mg and 10 mg tablets was still common practice in a small number of geographical areas across the country.

Aim and methodology

To reduce national variation in the prescription of oral methotrexate 10 mg tablets, for non-cancer treatment, by November 2021. A focused, five-stage quality improvement (QI) intervention was used, providing centralised support to a cohort of high prescribing integrated care systems (ICSs) in England.

Findings

23% (10) of ICSs in England were responsible for 76% of prescribing of methotrexate 10 mg tablets. Eight of these high prescribing ICSs participated in the QI intervention between March and November 2021. During the action period, the high prescribing cohort saw a 54% reduction in the prescribing of methotrexate 10 mg tablets, with seven ICSs seeing reductions of between 41% and 75%, resulting in reduced variation between the high prescribing ICSs and all other ICSs. The intervention was well received by ICSs with all making structural changes to their respective systems so that improvement would be sustained.

Conclusions

The success of this project raises several exciting opportunities for further work of this nature, particularly where this is significant variation in practice across the country.

Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression-risks, screening, diagnosis and management

BACKGROUND

One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune-based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence.

AIM

To review the screening, diagnostic practices and medical management of LTBI in patients with IBD.

METHODS

Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD.

RESULTS

Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon-gamma releasing assay or tuberculin skin test and chest X-ray. LTBI treatment in patients with IBD is scenario-dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD.

CONCLUSIONS

Proactive screening for LTBI is essential in patients with IBD undergoing immune-suppressing therapy and several therapeutic strategies are available. Reporting of real-world experience is essential to refining current management recommendations.

A Retrospective Database Cohort Study Evaluating the Association Between Immune Suppressive Therapy and the Development of Cancer in Patients with Atopic Dermatitis Within UK Primary Care

Introduction: First-line regular systemic treatment for atopic dermatitis (AD) in the UK consists of methotrexate, azathioprine, ciclosporin, or mycophenolate (immune-suppressive therapies [IST]). ISTs have been associated with malignancy, hence the need for evaluation for the relationship to the risk of developing cancer. Method: This retrospective cohort study utilising the Clinical Practice Research Datalink (CPRD) followed two cohorts with moderate or severe AD: one prescribed ISTs and one without. A total of 222,978 patients were included. The index date was the date of first IST prescription within primary care for the IST cohort, and the date of first potent topical steroid prescription from January 2001 to May 2021. Cohorts were propensity matched 1:1, resulting in 17,556 patients per cohort. Cox proportional hazard models were used to model the hazard of a cancer diagnosis. A secondary analysis was carried out on a restricted population, excluding patients with other comorbidities where ISTs were commonly prescribed. A further analysis explored the relation between the dose and the association with the risk of cancer. Results: Both the primary (hazard ratio: 1.01; 95% confidence interval: 0.94–1.08) and secondary (hazard ratio: 1.03; 95% confidence interval: 0.93–1.14) analyses did not show a significant difference in the hazard of a cancer code in the IST and non-IST cohorts. The exploratory dose–response analysis showed a higher risk of cancer associated with more prescriptions of IST per year. Conclusion: This study shows that amongst patients with moderate or severe AD, overall IST prescription in primary care is not associated with the onset of a cancer code. However, there is a trend with a higher risk of cancer coding with more prescriptions of IST.

Whether Screening for Non-alcoholic Fatty Liver Disease in Patients With Psoriasis Is Necessary: A Pilot Quality Improvement Project

Background

Psoriasis is a chronic inflammatory skin disease that is strongly associated with non-alcoholic fatty liver disease (NAFLD). Both conditions are associated with excess cardiovascular and liver-related morbidity and mortality. The severity of psoriasis correlates with the degree of liver inflammation and scarring, which can be further exacerbated by systemic immunomodulators such as methotrexate.

Currently, no clinical pathway exists to screen psoriasis patients for NAFLD in our Trust. We aimed to develop a shared clinical pathway between our hepatology and dermatology departments to allow early identification and management of NAFLD in this patient group.

Methods

A multidisciplinary team was assembled to identify patient priorities, management goals, and screening criteria. We identified gaps in our service and reviewed current clinical best practice guidelines. A clinical pathway was developed using a process map and revised according to feedback received. We piloted this pathway on a prospective cohort of psoriasis patients identified by our dermatology department. Patients were invited for transient elastography if fatty liver was identified on an ultrasound scan. Baseline demographics, biochemistry and imaging results were collected and analysed.

Results

Of 57 psoriasis patients, 30 (52.6%) had sonographic evidence of hepatic steatosis. The median age was comparable between groups with 56 and 55 years in the psoriasis-NAFLD (Ps-NAFLD) and no-NAFLD groups respectively. There were more males in the Ps-NAFLDgroup (56.7%) compared to the no-NAFLD group (37%). Fifteen out of 30 patients were eligible for transient elastography (two were excluded due to body habitus). Seven (53.8%) patients had no-to-mild fibrosis indicated by liver stiffness measurement (LSM) ≤7kPa, while six (46.1%) had moderate-to-severe fibrosis. Three (23.0%) patients had scores suggestive of cirrhosis (LSM>13kPa).

Conclusions

The introduction of a new shared-care pathway at our Trust has resulted in a streamlined way in which psoriasis patients can be screened and treated for NAFLD.

Global Guidelines in Dermatology Mapping Project (GUIDEMAP) - a systematic review of atopic dermatitis clinical practice guidelines: are they clear, unbiased, trustworthy and evidence based (CUTE)?

BACKGROUND

Clinical practice guidelines (CPGs) are essential in delivering optimum health care, such as for atopic dermatitis (AD), a highly prevalent skin disease. Although many CPGs are available for AD, their quality has not been critically appraised.

OBJECTIVE

To identify CPGs on AD worldwide and assess with validated instruments if those CPGs are clear, unbiased, trustworthy and evidence based (CUTE).

METHODS

We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library, Emcare, Epistemonikos, PsycINFO and Academic Search Premier for CPGs on AD published between 1 April 2016 and 1 April 2021. Additionally we hand searched prespecified guideline resources. Screening, data extraction and quality assessment of eligible guidelines were independently carried out by two authors. Instruments used for quality assessment were the Appraisal of Guidelines for Research and Evaluation (AGREE) II Reporting Checklist, the U.S. Institute of Medicine's (IOM) criteria of trustworthiness and Lenzer's Red Flags.

RESULTS

Forty CPGs were included, mostly from countries with a high socio-demographic index. The reported quality varied enormously. Three CPGs scored 'Excellent' on all AGREEII-domains: Columbia, the Netherlands and United Kingdom (UK; antimicrobials). Three CPGs scored 'Poor' on all domains: Poland (phototherapy), Romania and Serbia. We found no association between AGREEII-scores and a country's gross domestic product. One CPG fully met all nine IOM criteria (Malaysia) and two fully met eight (European dupilumab and UK antimicrobials). Three CPGs had no red flags: Malaysia, South Korea and UK antimicrobials. 'Applicability' and 'Rigour of development' were the lowest scoring AGREEII domains; 'Lack of external review', 'Updating procedures' and 'Rating strength of recommendations' met the least IOM criteria; and most red flags were for 'Limited or no involvement of methodological expertise' and 'No external review'. Management of conflict of interests (COI) appeared challenging. When constructs of the instruments overlapped, they showed high concordance, strengthening our conclusions.

CONCLUSIONS

Overall, many CPGs are not clear, unbiased, trustworthy or evidence based (CUTE) enough and lack applicability. Therefore improvement is warranted, for which using the AGREEII instrument is recommended. Some improvements can be easily accomplished through robust reporting. Others, such as transparency, applicability, evidence foundation and managing COI, might require more effort.

Therapeutic challenges of psoriasis in the HIV‑infected patient: A case report

Psoriasis can be paradoxically associated with human immunodeficiency virus (HIV) infection, having a prevalence similar to the general population but with a more severe evolution. In the genetically predisposed patients with the CW^*0602 haplotype, HIV infection can be a triggering factor and a first sign of infection, and lesions can spontaneously remit with immune reconstruction after antiretroviral therapy. Our patient is a 34 year-old male with recent HIV infection, in spite of being for over 10 years the partner of an HIV-positive patient with whom the patient has two HIV-positive children. The patient was diagnosed with psoriasis 7 years ago and was treated topically. The physical examination at HIV diagnosis was overall favorable, with skin findings compatible with disseminated vulgar psoriasis. Following antiretroviral treatment with Triumeq the patient had a favorable viral response, with complete viral suppression after 12 weeks, but the pre-existent psoriasis lesions worsened. Methotrexate (MTX) treatment followed for 12 weeks, with partial improvement of psoriatic dermatitis. This medication was continued for 1 year, but the lesions reappeared, possibly due to treatment resistance. MTX treatment for psoriasis in the HIV-infected patient was beneficial, but limited to one year, leaving biologics as possible treatment following therapy under strict monitoring for adverse effects, T-lymphocyte CD4⁺ and viral levels.

"His first word was 'cream'." The burden of treatment in pediatric atopic dermatitis-A mixed methods study

The burden of treatment (BOT) is the workload of health care experienced by patients with chronic conditions and consequences on well-being. This study aimed to assess the BOT of atopic dermatitis (AD) on children and caregivers using mixed methods. The quantitative component of this mixed methods study involved the Treatment Burden Questionnaire. The qualitative component involved interviews with parents of children with moderate-severe AD. The questionnaire was completed by 168 parents; 32.1% had mild AD, 39.9% had moderate AD, and 28% had severe AD. The average burden score was 3.5 (out of 10). Average burden scores were low in mild AD (1.0 out of 10) and were proportionally higher in moderate (3.9 out of 10) and severe (5.8 out of 10) AD (p < 0.001). Increased frequency of therapy had increased perceived burden. In moderate-severe AD, oral therapy was rated as less burdensome than topical therapies. Semi-structured interviews were conducted with 15 parents of children with moderate-severe AD. Thematic analysis grouped experiences into health care burden, treatment burden, and financial burden. Insights from health care burden analysis included "mixed messages," "treatment futility," and "expectant resolution." Insights from treatment burden included treatment routine, schooling impact, and "topical-sparing" with systemic treatment. Factors of financial burden included topical treatments, clothing, and health care visits. Moderate-severe AD is associated with high BOT, particularly related to topical therapies, which may be reduced by systemic treatment. All physicians treating children with AD should avoid potentially damaging communication regarding mixed messages, treatment futility, and expectant resolution.

Methotrexate in erythema nodosum leprosum: Pitfalls to avoid

We read with interest the short report by Rani et al. entitled "An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases." The article describes two cases of erythema nodosum leprosum (ENL) with 'atypical features' and good response to low dose methotrexate. The authors address a few concerns regarding methotrexate in ENL, emphasizing the rational usage of this agent.

Reference interval for type III procollagen (PIIINP) using the Advia centaur PIIINP assay in adults and elderly

OBJECTIVE

The amino-terminal peptide of type III procollagen (PIIINP) is a byproduct of type III collagen synthesis that exhibits promise as a biomarker of fibrosis, specifically in monitoring hepatic fibrosis in methotrexate treated patients. The Advia Centaur^® PIIINP assay is developed for track-based automated laboratory systems and is suitable for large volume analysis. Reference intervals in children and younger adults have been published previously. Here we measured PIIINP to determine reference ranges, specifically including elderly patients, for whom such are currently lacking.

METHODS

Samples were collected from subjects ranging from 20 to 98 years of age. Blood donors and clinical samples from primary care patients were used for reference interval calculation. Samples were analysed using the Advia Centaur^® PIIINP assay. After exclusion of samples high in alanine transaminase (AST), aspartate transaminase (ALT), and C-reactive protein (CRP) 386 samples were used in the reference interval calculation.

RESULTS AND CONCLUSION

We determined the following reference interval for the Advia Centaur^® PIIINP assay: the lower limit of the reference interval (2.5% percentile with 95% CI) was 4.42 (4.20-4.65) µg/L and the upper limit of the reference interval (97.5% percentile 95% CI) 16.0 (15.04-17.02) µg/L.No significant differences in mean PIIINP concentrations were found between men and women. While differing mean PIIINP concentrations were seen among subjects in different age groups, the differences were small and partitioning of reference range was determined not to be necessary.

On which evidence can we rely when prescribing off-label methotrexate in dermatological practice? - a systematic review with GRADE approach

If an authorized drug is prescribed for a use that is not described in the Summary of Product Characteristics, this is defined as 'off-label use.' Methotrexate is often used off-label for dermatological indications. Off-label use is permitted if physicians can justify the treatment based on scientific evidence available to them. Our objective here was therefore to summarize the evidence for the effectiveness, efficacy, and safety of the dermatological off-label use of methotrexate in a systematic review. We searched MEDLINE, EMBASE, and CENTRAL for studies for evidence on the effectiveness, efficacy, and safety of the off-label use of methotrexate in dermatological indications up to November 2019. We used the GRADE system to rate the quality of the evidence. The search retrieved 34,583 hits of which 3566 were selected after the title and abstract screening. After the full-text screening, 143 studies were included, which involved 3688 patients in total. We found low-quality evidence for the effectiveness, efficacy, and safety of the off-label use of methotrexate in 31 dermatological diseases. To optimize the quality of evidence to support off-label use, we need high-quality studies in which well-characterized patients are treated with standardized treatments regimens using well-validated outcomes relevant to patients and physicians.

Noninvasive assessment of liver fibrosis in Crohn's disease patients exposed to methotrexate

BACKGROUND

Methotrexate is widely used to treat some inflammatory chronic disorders, though it is hampered by the risk of liver fibrosis. Many recommendations have been made to assess methotrexate-related hepatotoxicity, including liver biopsy. However, other noninvasive methods to assess liver fibrosis have been developed and could be implemented for patients treated with methotrexate.

AIM

The aim of the study was to compare the prevalence of liver fibrosis by means of noninvasive methods [aspartate transaminase-to-platelet ratio index (APRI) Forns index, and transient elastography] in patients with Crohn's disease exposed or not to methotrexate, and to identify risk factors for liver fibrosis.

METHODS

Prospective, cross-sectional study. All patients with Crohn's disease exposed to methotrexate were included and compared to an unselected cohort of outpatients with Crohn's disease never exposed to methotrexate.

RESULTS

A total of 84 patients with Crohn's disease, 56 exposed to methotrexate, and 28 controls, were included. Significant liver fibrosis was found in 7% of methotrexate-exposed patients with Crohn's disease and 10% of controls as measured by transient elastography, and in 7% of controls as measured by the Forns index. No cases of liver fibrosis were detected by APRI. Only alcohol consumption, diabetes mellitus, and age were associated with significant liver fibrosis.

CONCLUSIONS

Significant liver fibrosis is uncommon among patients with Crohn's disease, even among those exposed to methotrexate. The risk of liver fibrosis in Crohn's disease seems to depend on common risk factors for liver disease.

Psoriasis: a brief overview

Psoriasis is a clinically heterogeneous lifelong skin disease that presents in multiple forms such as plaque, flexural, guttate, pustular or erythrodermic. An estimated 60 million people have psoriasis worldwide, with 1.52% of the general population affected in the UK. An immune-mediated inflammatory disease, psoriasis has a major genetic component. Its association with psoriatic arthritis and increased rates of cardiometabolic, hepatic and psychological comorbidity requires a holistic and multidisciplinary care approach. Psoriasis treatments include topical agents (vitamin D analogues and corticosteroids), phototherapy (narrowband ultraviolet B radiation (NB-UVB) and psoralen and ultraviolet A radiation (PUVA)), standard systemic (methotrexate, ciclosporin and acitretin), biologic (tumour necrosis factor (TNF), interleukin (IL)-17 and IL-23 inhibitors) or small molecule inhibitor (dimethyl fumarate and apremilast) therapies. Advances in the understanding of its pathophysiology have led to development of highly effective and targeted treatments.

Use of Methotrexate in the Treatment of Moderate to Severe Plaque Psoriasis in France: A Practice Survey

Purpose

To evaluate the modalities of methotrexate prescription for moderate to severe psoriasis by dermatologists in France.

Patients and Methods

We performed a national online practice survey between October and December 2020.

Results

A total of 254 dermatologists responded, 237 reported prescribing methotrexate for moderate to severe psoriasis in adults, of which 57% as a first line systemic treatment. Nineteen percent reported performing a test dose at the initiation of treatment. Methotrexate was prescribed orally in 54.7% of cases, subcutaneously in 44.8% of cases and intramuscularly in 0.4% of cases. The initial weekly dose of methotrexate was <15 mg for 30% of the dermatologists and ≥15 mg for 70% of them. Two hundred and three dermatologists had already change the route of administration for methotrexate from the oral to injectable form due to poor tolerance (48.3%), lack of efficacy (35%) or lack of compliance (16.7%). Two hundred thirty-four dermatologists (98.7%) reported prescribing folic acid with methotrexate, and 79.3% reported prescribing tests evaluating the risk of hepatic fibrosis. Forty-three percent of dermatologists have not initiated or have reduced their prescriptions since the beginning of the pandemic of COVID-19. Prescribing patterns were different according to the type of practice (private practice versus hospital/mixed practice).

Conclusion

Methotrexate is used by the majority of dermatologists interviewed for moderate to severe psoriasis in adults, with heterogeneity of practices.

Is methotrexate hepatotoxicity associated with cumulative dose? A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Methotrexate (MTX) is widely used in various medical specialties. However, hepatotoxicity is an ongoing concern and this is thought to be directly associated with cumulative dose. We sought to synthesise the published literature to evaluate the association between methotrexate hepatotoxicity and cumulative dose.

METHODS

A systematic review of Medline (PubMed) EMBASE, CINAHL and The Cochrane Library was performed. Full texts of articles were examined, and excluded articles were recorded with reasons for exclusion. A meta-analysis of correlation coefficients was performed using Fisher's z-transformation and a random effects model. Cochran's Q-test and the I² statistic were calculated to assess heterogeneity.

RESULTS

A total of 35 studies met inclusion criteria. Measures of hepatotoxicity were highly varied and included liver biopsy, elastography, FibroTest, biochemical tests and scoring systems (Fib-4, APRI, AST:ALT). Some studies analysed for the association with MTX cumulative dose using more than one modality. Overall, 38 analyses found no significant association between MTX cumulative dose and hepatoxicity vs eight that identified a significant association. The pooled correlation coefficient from five studies which utilised elastography was 0.18 (95% CI, -0.09 to 0.42), with significant heterogeneity between studies (P < 0.0001), I²  = 92%).

CONCLUSIONS

Our synthesis of a large volume of studies in this review found no significant association between MTX cumulative dose and hepatotoxicity, both in terms of vote counting and with regard to the meta-analysis of correlation coefficients from studies that utilised elastography. This challenges the long-held belief that liver injury is a direct result of drug accumulation.

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

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

Methotrexate and prednisolone study in erythema nodosum leprosum (MaPs in ENL) protocol: a double-blind randomised clinical trial

INTRODUCTION

Erythema nodosum leprosum (ENL) is an immunological complication of leprosy. ENL results in morbidity and disability and if it is not treated can lead to death. The current treatment consists of thalidomide or high doses of oral corticosteroids for prolonged periods. Thalidomide is not available in many leprosy endemic countries. The use of corticosteroids is associated with morbidity and mortality. Identifying treatment regimens that reduce the use of corticosteroids in ENL is essential. Methotrexate (MTX) is used to treat many inflammatory diseases and has been used successfully to treat patients with ENL not controlled by other drugs, including prednisolone and thalidomide. We present the protocol of the 'MTX and prednisolone study in ENL' (MaPs in ENL) a randomised controlled trial (RCT) designed to test the efficacy of MTX in the management of ENL.

METHODS AND ANALYSIS

MaPs in ENL is an international multicentre RCT, which will be conducted in leprosy referral centres in Bangladesh, Brazil, Ethiopia, India, Indonesia and Nepal. Patients diagnosed with ENL who consent to participate will be randomly allocated to receive 48 weeks of weekly oral MTX plus 20 weeks of prednisolone or 48 weeks of placebo plus 20 weeks of prednisolone. Participants will be stratified by type of ENL into those with acute ENL and those with chronic and recurrent ENL. The primary objective is to determine whether MTX reduces the requirement for additional prednisolone. Patients' reported outcome measures will be used to assess the efficacy of MTX. Participants will be closely monitored for adverse events.

ETHICS AND DISSEMINATION

Results will be submitted for publication in peer-reviewed journals. Ethical approval was obtained from the Observational/Interventions Research Ethics Committee of the London School of Hygiene & Tropical Medicine (15762); The Leprosy Mission International Bangladesh Institutional Research Board (in process); AHRI-ALERT Ethical Review Committee, Ethiopia; Ethics Committee of the Managing Committee of the Bombay Leprosy Project; and The Leprosy Mission Trust India Ethics Committee; the Nepal Health and Research Council and Health Research Ethics Committee Dr. Soetomo, Indonesia. This study is registered at www.clinicaltrials.gov. This is the first RCT of MTX for ENL and will contribute to the evidence for the management of ENL.Trial registration numberNCT 03775460.

Acute anejaculation, hypogonadism, and fertility preservation in the setting of neurosarcoidosis: case report and literature review

Objective

To examine fertility preservation techniques in the setting of neurosarcoidosis, and to review the impact of corticosteroid and methotrexate therapy on fertility.

Design

Case report of a patient with infertility secondary to anejaculation associated with spinal neurosarcoidosis, treated with systemic corticosteroids and methotrexate.

Setting

Academic tertiary-care hospital.

Patient(s)

A 39-year-old man presented with neurosarcoidosis complicated by acute anejaculation, erectile dysfunction, and hypogonadism. He underwent fertility consultation and sperm cryopreservation before initiating methotrexate therapy. His pretreatment total testosterone was low, at 157 ng/dL.

Intervention(s)

Unsuccessful pharmacologic therapy and penile vibratory stimulation (PVS) were followed by microdissection testicular sperm extraction (microTESE). Clomiphene was administered for optimization of spermatogenesis before microTESE.

Main Outcome Measure(s)

Vials of cryopreserved sperm, testis histopathology, and serum testosterone levels.

Result(s)

Eight vials of viable sperm were harvested by means of micro-TESE and cryopreserved. Despite intraoperative appearance of hypospermatogenesis, 90% of seminiferous tubules had active germ cell sloughing. Total testosterone increased to 278 ng/dL 2 months after initiating clomiphene.

Conclusion(s)

Conventional fertility preservation techniques may be effective in the setting of neurosarcoidosis-induced infertility owing to largely intact spermatogenesis. PVS, though not effective for this patient, should be considered along with electroejaculation, given high success rates in other patients with neurogenic anejaculation. Corticosteroid-mediated hypogonadism also must be considered in these patients, because it can negatively affect downstream spermatogenesis. In addition, evidence for the impact of paternal methotrexate exposure on fertility is limited and requires further investigation. As such, fertility consultation before initiating methotrexate is highly recommended.

Weight gain in patients with severe atopic dermatitis treated with dupilumab: a cohort study

BACKGROUND

Dupilumab, targeting the interleukin-4α receptor and inhibiting the action of interleukin-4 and interleukin-13, was recently approved for treatment of moderate to severe atopic dermatitis. There is limited data on long-term effects and safety among patients with severe atopic dermatitis treated with dupilumab. Weight gain was observed among patients treated with dupilumab in our clinic. The aim was to describe weight change in a cohort study of patients with severe atopic dermatitis treated with dupilumab from baseline to follow-up after 12 months, and to analyze if weight change was associated with effect of treatment, reported appetite, and/or disturbed night sleep due to itching.

METHODS

All patients with atopic dermatitis receiving systemic treatment at the Unit of Dermatology, Karolinska University Hospital, have been registered and monitored consecutively since January 2017. This cohort constituted all patients who started treatment on dupilumab or methotrexate between 10 January 2017 and 30 June 2019 with at least 6 months of follow-up within the study period. The following variables were monitored at start of and during treatment: Eczema Severity Score Index, Patient-Oriented Eczema Measure, visual analogue scale for pruritus 10 cm, Montgomery-Åsberg Depression Rating Scale, Dermatology Life Quality Index, and weight. Data analyses were performed using two-sample Wilcoxon-Mann-Whitney rank-sum test, or the Wilcoxon matched-pairs sign-rank test with a p-value < 0.05 considered as statistically significant.

RESULTS

Patients treated with dupilumab (n = 12) gained weight (mean 6.1 kg, range [0.1-18.0], p = 0.002) after 1 year on treatment. The majority of patients showed a good response to treatment with dupilumab (n = 11); at follow-up at 6, 9, or 12 months, they reached EASI-90 (n = 6), EASI-75 (n = 4), or EASI-50 (n = 1). There was no significant association between weight gain and treatment response, reported appetite, or disturbed night-sleep due to itch. Patients treated with methotrexate showed no significant weight change (n = 8).

CONCLUSIONS

To our knowledge, this is the first report on a possible association between weight gain and dupilumab treatment; the extent of the association is yet to be seen, as is the mechanism behind this finding.

"Hepatic toxicity by methotrexate with weekly single doses associated with folic acid in rheumatoid and psoriatic arthritis. What is its real frequency?"

INTRODUCTION AND OBJECTIVES

Liver injury caused by methotrexate (MTX) has mostly been investigated without applying criteria for the assessment of causality of drug induced liver injury (DILI). Hence, the existence of DILI by MTX in many cases is debatable. This study aimed to describe the frequency and characteristics of liver injury caused by MTX, applying DILI diagnostic criteria.

MATERIAL AND METHODS

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients who were treated with MTX in association with folic acid were included. Serial determinations of alanine amino transferase (ALT) and aspartate amino transferase (AST) were performed. The Roussel Uclaf Causality Assessment Method (RUCAM) was applied in cases of increases of ALT/AST over 1.5 upper limit of normal. Liver biopsy was considered when the total cumulative dosage (TCD) of MTX was ≥3.5g.

RESULTS

A total of 43 patients were analyzed (median follow up 32 (range: 1-48) months; 3.33 ALT/AST determinations per year). Five subjects presented an increase of ALT/AST. All presented a RUCAM score for MTX≤2 (improbable). Three had a RUCAM score for non-steroidal anti-inflammatory drugs ≥7 (probable) and two patients presented non-alcoholic fatty liver disease. Five patients with no other cause for liver disease consented to liver biopsy (TCD MTX: median 5.1; range: 3.5-7.4g). No significant fibrosis or steatosis was evident on histology.

CONCLUSIONS

No biochemical or significant histological liver toxicity for MTX was demonstrated when applying causality criteria for DILI. More studies with this methodology are necessary in order to improve the assessment of its frequency.

Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature

Oral systemic therapies are important treatment options for patients with moderate-to-severe psoriasis, either as monotherapy or in therapy-recalcitrant cases as combination therapy with phototherapy, other oral systemics or biologics. Long-term treatment is needed to maintain sufficient disease control in psoriasis, but continuous use of systemic treatments is limited by adverse events (AEs) and cumulative toxicity risks. The primary aim of this comprehensive literature review was to examine the long-term safety profiles of oral agents commonly used in the treatment of adults with psoriasis. Searches were conducted in EMBASE and PubMed up to November 2018, and 157 relevant publications were included. Long-term treatment with acitretin could be associated with skeletal toxicity and hepatotoxicity, although evidence for skeletal toxicity is mixed and hepatotoxicity is rare, particularly at low doses. Other safety issues include hyperlipidaemia and potential for teratogenicity up to 2-3 years after discontinuation of treatment. There is a paucity of data on long-term treatment with apremilast. Continued exposure to apremilast does not seem to increase the incidence of common AEs, such as gastrointestinal (GI) AEs, upper respiratory tract infections and headache, while the long-term risks for depression, suicidal thoughts and weight loss are unknown. Long-term ciclosporin treatment is associated with renal toxicity, hypertension, non-melanoma skin cancer, neurological AEs and GI AEs. Long-term methotrexate treatment is associated with hepatotoxicity, GI AEs, haematological toxicity, renal toxicity and alopecia. Finally, long-term treatment with fumaric acid esters (FAE) is associated with GI AEs, flushing, lymphocytopenia, proteinuria and elevated liver enzymes. Median drug survival estimates varied considerably: ~  2.9-9.7 months for apremilast; ~ 5.4 months for ciclosporin; ~ 8.6 months for acitretin; ~ 12.1-21.6 months for methotrexate; and ~  54.8 months for FAE. These long-term safety profiles may help to guide clinicians to select the optimal oral systemic treatment for the long-term treatment of psoriasis in adults.

Adherence to guidelines across different specialties to prevent infections in patients undergoing immunosuppressive therapies

BACKGROUND

Substantial numbers of patients are now receiving either immunosuppressive therapies or chemotherapy. There are significant risks in such patients of developing opportunistic infections or re-activation of latent infections, with higher associated morbidity and mortality. The aim of this quality improvement project was to determine how effective 5 different specialties were in assessing and mitigating risks of developing opportunistic infections or re-activation of latent infections in patients undergoing immunosuppressive therapies.

METHODS

This was a single centre audit where records of patients attending clinics providing immunosuppressive therapies were reviewed for the following: evidence of screening for blood-borne virus [BBV] infections, varicella and measles immunity, latent/active TB or hypogammaglobulinaemia, and whether appropriate vaccines had been advised or various infection risks discussed. These assessments were audited against both national and international guidelines, or a cross-specialty consensus guideline where specific recommendations were lacking. Two sub-populations were also analysed separately: patients receiving more potent immunosuppression and black and minority ethnic [BME] patients,.

RESULTS

For the 204 patients fulfilling the inclusion criteria, BBV, varicella/measles and latent TB screening was inconsistent, as was advice for vaccinations, with few areas complying with specialty or consensus guidelines. Less than 10% of patients in one specialty were tested for HIV. In BME patients screening for HIV [60%], measles [0%] and varicella [40%] immunity and latent [30%] or active [20%] TB was low. Only 38% of patients receiving potent immunosuppression received Pneumocystis prophylaxis, with 3 of 4 specialties providing less than 15% of patients in this category with prophylaxis.

CONCLUSIONS

Compliance with guidelines to mitigate risks of infection from immunosuppressive therapies was either inconsistent or poor for most specialties. New approaches to highlight such risks and assist appropriate pre-immunosuppression screening are needed.

A dermatologist perspective in the pharmacological treatment of patients with psoriasis and psoriatic arthritis

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis in 20-30% of patients. PsA presents as a heterogeneous disease involving different domains and burdened by an important impact on function and quality of life.

AREAS COVERED

Dermatologists play an important role in the early detection of PsA because in most patients PsA develop after cutaneous psoriasis. The ideal goal of treating patients with PsA is to optimize the controls of symptoms, improve quality of life, and prevent structural damage and disability. The choice of treatment in patients with PsA should take into account also the skin signs and symptoms. Treatment options include NSAIDs, synthetic DMARDSs, anti-TNF-α agents, anti-IL-12/IL-23 agents, anti-IL-17 agents, PDE4 inhibitors, JAK inhibitors, and co-stimulatory blockers. A narrative review based on electronic searches on PubMed® database was performed. Original articles assessing either the role of the dermatologist in the management of PsA and the available treatments for PsA were included.

EXPERT OPINION

Among different treatments, some drugs show more efficacy in joint signs and symptoms, and poor response on the skin and vice versa. The perspective of the dermatologist in a multidisciplinary setting may provide a helpful tool in the management of patients with PsA.