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Damiani G, Amerio P, Bardazzi F, Carrera CG, Conti A, Cusano F, Dapavo P, DeSimone C, El Hachem M, Fabbrocini G, Gisondi P, Loconsole F, Micali G, Neri I, Parodi A, Piaserico S, Romanelli M, Stingeni L, Pigatto PDM. Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00930-2. [PMID: 37210684 DOI: 10.1007/s13555-023-00930-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/17/2023] [Indexed: 05/22/2023] Open
Abstract
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.
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Affiliation(s)
- Giovanni Damiani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy.
- Italian Center of Precisione Medicine and Chronic Inflammation, University of Milan, Milan, Italy.
- UOC Dermatology, Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161, Milan, Italy.
| | - Paolo Amerio
- Dermatologic Clinic, Department of Medicine and Aging Science, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Federico Bardazzi
- Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo G Carrera
- Fondazione Cà Granda IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Andrea Conti
- Dermatology Unit, Ospedale Infermi di Rimini, AUSL Romagna, Rimini, Italy
| | | | - Paolo Dapavo
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Clara DeSimone
- DermatologiaDipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - May El Hachem
- Dermatology Unit and Genodermatosis Research Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Francesco Loconsole
- Department of Biomedical Sciences and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | | | - Iria Neri
- Dermatology, Sant'Orsola-Malpighi Polyclinic University Hospital-IRCCS, University of Bologna, Bologna, Italy
| | - Aurora Parodi
- Dermatology Clinic, DISSAL, Polyclinic Hospital San Martino-IRCCS, University of Genoa, Genoa, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Luca Stingeni
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Paolo D M Pigatto
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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2
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Gelfand JM, Wan J, Zhang H, Shin DB, Ogdie A, Syed MN, Egeberg A. Risk of liver disease in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis receiving methotrexate: A population-based study. J Am Acad Dermatol 2021; 84:1636-1643. [PMID: 33607181 DOI: 10.1016/j.jaad.2021.02.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/26/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with psoriatic disease may be more susceptible to methotrexate hepatotoxicity than those with rheumatoid arthritis (RA); however, direct evidence supporting this notion is lacking. OBJECTIVE To compare liver disease risk among patients with psoriasis (PsO), psoriatic arthritis (PsA), or RA receiving methotrexate. METHODS In a population-based cohort study, Danish individuals with PsO, PsA, or RA receiving methotrexate between 1997 and 2015 were compared according to 4 disease outcomes: mild liver disease, moderate-to-severe liver disease, cirrhosis, and cirrhosis-related hospitalization. RESULTS Among 5687, 6520, and 28,030 patients with PsO, PsA, and RA, respectively, the incidence rate of any liver disease was greatest for PsO, followed by PsA, and lowest for RA. Compared with patients with RA, patients with PsO were 1.6-3.4 times more likely to develop at least one of the liver disease outcomes, whereas those with PsA were 1.3-1.6 times more likely to develop mild liver disease and cirrhosis after adjusting for demographics, smoking, alcohol use, comorbidities, and methotrexate dose. LIMITATIONS Confounding due to unmeasured variables, misclassification, and surveillance bias. CONCLUSION PsO, PsA, and RA differentially influence liver disease risk in the setting of methotrexate use independent of other major risk factors. More conservative monitoring should be considered in patients receiving methotrexate for psoriatic disease, particularly in PsO patients.
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Affiliation(s)
- Joel M Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Joy Wan
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - He Zhang
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Daniel B Shin
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexis Ogdie
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Rheumatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Maha N Syed
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexander Egeberg
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Chularojanamontri L, Wongpraparut C, Silpa-Archa N, Chaiyabutr C, Pruksaeakanan C, Klinniyom A, Junnu S, Srisawat C. Patient-ready syringes containing 25 mg/mL methotrexate can be kept at temperature ranging from 4 °C to 37 °C for up to 12 weeks for use in psoriatic and rheumatologic conditions. J DERMATOL TREAT 2020; 33:1023-1028. [PMID: 32700608 DOI: 10.1080/09546634.2020.1800570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Methotrexate (MTX) is a mainstay drug in the treatment of psoriatic and rheumatologic conditions. Subcutaneous MTX has become a feasible treatment alternative with the development of prefilled syringes or autoinjectors containing MTX solution that can be self-administered by the patient at home. However, MTX prefilled auto-injector pens are still not available in some countries. OBJECTIVE This study aimed to investigate the stability and sterility of 25 mg/mL MTX solution in a disposable plastic syringe over a 12-week period under light protection at temperatures of 4 °C, 25 °C, and 37 °C. METHODS This study was conducted during November 2019 to February 2020 at the Faculty of Medicine Siriraj Hospital, Mahidol University. Stability was evaluated using ultra-high-performance liquid chromatography technique, and sterility was assessed by cultures for bacterial and fungal contamination. RESULTS Our results revealed that patient-ready syringes containing 25 mg/mL MTX solution can be prepared in advance and kept for up to 12 weeks under light protection, and they can be kept at temperatures ranging from 4 to 37 °C. CONCLUSION This system for delivering MTX to patients that are refractory to or intolerant of oral MTX via a self-administered pre-filled syringe is both efficient and easy to implement in care settings where commercially alternatives are not yet available.
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Affiliation(s)
- Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanisada Wongpraparut
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narumol Silpa-Archa
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayada Chaiyabutr
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chutipon Pruksaeakanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalika Klinniyom
- Pharmacy Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarawut Junnu
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatchawan Srisawat
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Busger op Vollenbroek FTM, Doggen CJM, Janssens RWA, Bernelot Moens HJ. Dermatological guidelines for monitoring methotrexate treatment reduce drug-survival compared to rheumatological guidelines. PLoS One 2018; 13:e0194401. [PMID: 29570708 PMCID: PMC5865732 DOI: 10.1371/journal.pone.0194401] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 03/04/2018] [Indexed: 01/30/2023] Open
Abstract
Background Methotrexate (MTX) is widely used as disease modifying treatment for psoriasis and psoriatic arthritis (PsA). Rheumatological and dermatological guidelines to prevent MTX-induced adverse events diverge in the number and frequency of blood tests. These differences are not based on evidence indicating a higher risk for patients with psoriasis compared to PsA or rheumatic arthritis (RA). This raises the question if multiple testing increases safety, or results in false positive signals potentially leading to early withdrawal of an effective treatment. Objective Compare the effects of MTX monitoring strategies by rheumatologists and dermatologists regarding drug survival, reasons for withdrawal and safety. Methods Retrospective follow-up of all patients diagnosed with psoriasis by dermatologists or PsA by rheumatologists. Included were consecutive patients who started methotrexate (MTX) between 2006 and 2012 and had a scheduled follow-up by dermatologist or rheumatologist. Exclusions were: drug not started after the first prescription or incomplete availability of lab data. Data were extracted from electronic records: start and stop dates and dosing of MTX; treatment with folic acid and dose; reasons for withdrawal of MTX; numbers of blood sampling and types of laboratory tests performed for MTX safety; number of abnormal tests; occurrence of any serious adverse event (SAE). Results 190 Psoriasis and 196 PsA patients starting methotrexate (MTX) were included. Age and sex were comparable. PsA patients used higher initial and maximum doses of MTX and folic acid, but psoriasis patients had a higher frequency of abnormal laboratory results (0.14 vs 0.03 per treatment month, p<0.001), resulting in a striking difference in withdrawal of MTX for abnormal liver enzymes (15.8% vs 3.6%, p<0.001). In PsA patients MTX was withdrawn less frequently for ineffectiveness (15.8 vs 24.2%, p<0.05) leading to longer drug survival in the first course of treatment (37.4±30 vs 18.8±19.1 months). Repeated courses of MTX were more often prescribed by rheumatologists than by dermatologists. There were no significant differences in the occurrence of SAE (psoriasis 0.0041 vs PsA 0.0038 per treatment month) or death (1.6% vs 2.0%) between these groups. Hospital admissions related to infection were recorded in 6 (3.1%) PsA vs 4 (2.1%) psoriasis patients. Conclusion Strict monitoring by dermatologists resulted in more abnormal findings, which reduced drug survival of MTX. The limited monitoring strategy by rheumatologists was not associated with more SAEs. Further research in other populations is needed to confirm whether reduced intensity of monitoring can optimize the use of MTX with sufficient long-term safety.
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Affiliation(s)
| | - Carine J. M. Doggen
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Vena GA, Cassano N, Iannone F. Update on subcutaneous methotrexate for inflammatory arthritis and psoriasis. Ther Clin Risk Manag 2018; 14:105-116. [PMID: 29386902 PMCID: PMC5767093 DOI: 10.2147/tcrm.s154745] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Methotrexate (MTX) is one of the mainstays of treatment for several immune-mediated inflammatory joint and skin diseases, especially rheumatoid arthritis (RA) and moderate-to-severe psoriasis. Oral MTX has been used for the treatment of such diseases for decades for many reasons. There is, however, a relevant interpatient variability of clinical and safety outcomes that can also be related to differences in patients’ individual pharmacogenomic profile. Orally administered MTX has been found to have a saturable intestinal absorption and nonlinear pharmacokinetics, with significant consequences on drug bioavailability and clinical efficacy. The current evidence shows that parenterally administered MTX results in rapid and complete absorption, higher serum levels, and less variable exposure than oral dosing. The use of parenteral MTX, particularly when administered as a subcutaneous (SC) injection, has recently raised great interest in order to overcome the limitations of oral MTX. The effectiveness and safety of SC MTX have mostly been assessed in rheumatological settings, especially in patients with RA. There are only a limited number of data on SC MTX in juvenile idiopathic arthritis and even fewer in psoriatic disease. Various clinical experiences have suggested that SC MTX is more effective than oral MTX and may provide significant benefit even in patients in whom oral MTX proved to be inadequate. The increased efficacy of SC MTX resulting from higher drug exposure compared with oral MTX has been associated with a similar safety profile and in various reports even with a lower frequency of gastrointestinal complaints. The aim of this article was to review the available literature data on SC MTX treatment of inflammatory arthritis, with special emphasis on RA and psoriasis, examining differences with oral MTX treatment. A brief mention of pharmacokinetics, pharmacodynamic features and pharmacoeconomic considerations is also given.
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Affiliation(s)
- Gino Antonio Vena
- Dermatology and Venereology Private Practice, Bari.,Dermatology and Venereology Private Practice, Barletta
| | - Nicoletta Cassano
- Dermatology and Venereology Private Practice, Bari.,Dermatology and Venereology Private Practice, Barletta
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Bari, Italy
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Puig L. Methotrexate: new therapeutic approaches. ACTAS DERMO-SIFILIOGRAFICAS 2013; 105:583-9. [PMID: 23434058 DOI: 10.1016/j.ad.2012.11.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 11/26/2012] [Accepted: 11/29/2012] [Indexed: 11/15/2022] Open
Abstract
Although the first study on the efficacy of methotrexate in the treatment of psoriasis was reported in 1958, scientific evidence for this indication has been scant until quite recently. We now have new data on the pharmacokinetics and mechanism of action of methotrexate and new subcutaneous formulations that have improved the bioavailability, efficacy, and ease of administration of the drug. The results of recent clinical trials comparing methotrexate with several biologic agents have shown it to be the first-line therapy among the classic systemic treatments for psoriasis. Moreover, the incremental cost-effectiveness ratio for subcutaneous methotrexate has been shown to be superior to that of ciclosporin, adalimumab, and infliximab.
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Affiliation(s)
- L Puig
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España.
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