Methotrexate for psoriasis: current European practice. A postal survey

A dermatologist guide to immunogenicity

Dermatologists should be aware that autoantibody formation may occur after the initiation of biologic therapy. This phenomenon has been referred to as immunogenicity and biologic fatigue. Because of this, patients may experience loss of clinical efficacy to a particular drug. To combat this phenomenon, low-dose immunomodulators may be used in hopes of preventing autoantibodies. We review the current literature and provide a basic treatment algorithm for patients with moderate to severe psoriasis.

End-stage methotrexate-related liver disease is rare and associated with features of the metabolic syndrome

BACKGROUND

Methotrexate (MTX) is one of the most frequently prescribed drugs in contemporary medicine with a well-recognised hepatotoxic potential, for which stringent laboratory and histological surveillance has long been advocated.

AIM

To estimate the population burden of end-stage methotrexate-related liver disease (MTX-LD) in the United States and identify independent host risk factors for this disease entity.

METHODS

We analysed the records of all individuals who had been listed for, and/or received, liver transplantation in the United States, as reported to the Organ Procurement and Transplantation Network between 1 October 1987 and 31 December 2011, and identified those whose liver disease was attributed, wholly or partly, to MTX therapy. We also compared the demographic and clinical characteristics of adult individuals with MTX-LD with those listed and/or transplanted for alcoholic liver disease (ALD, n = 43,285), non-alcoholic steatohepatitis (NASH, n = 7569) and primary sclerosing cholangitis (PSC, n = 8526) using the adjusted odds ratios (AORs) derived from multi-variable logistic regression models.

RESULTS

Of 158 904 adults who had been listed for, and/or received, liver transplantation during the study period, only 117 (0.07%) had MTX-LD. Compared with individuals with ALD and PSC, those with MTX-LD were more likely to be older (AORs per 5-year increase: 1.27, P < 0.001 and 1.33, P < 0.001 respectively); female (AORs: 1.78, P = 0.003 and 3.87, P < 0.001); Caucasian (AORs: 3.03, P = 0.001 and 2.05, P = 0.04); and diabetic (AORs: 2.76, P < 0.001 and 4.12, P < 0.001). With the exception of Caucasian ethnicity (AOR: 1.94, P = 0.05), the odds of these characteristics did not differ from individuals with NASH. The odds of elevated body mass index among MTX-LD individuals were higher than those with PSC (AOR per 5 kg/m(2) : 1.51, P < 0.001); similar to those with ALD (AOR per 5 kg/m(2) :1.15, P = 0.1); and lower than those with NASH (AOR per 5 kg/m(2) : 0.66, P < 0.001).

CONCLUSIONS

The United States population burden of end-stage methotrexate-related liver disease is likely to be exceedingly small, suggesting the need for reappraisal of current hepatotoxicity surveillance guidelines. The risk factor profile of methotrexate-related liver disease supports the notion that it may share a common pathogenesis with NASH.

Folic acid in general medicine and dermatology

Folic acid is a vitamin B essential for the integrity and function of DNA. Relative deficiency of folic acid may occur in conditions such as pregnancy and hyperproliferative or chronic inflammatory disorders. Folic acid supplementation has been proven to be beneficial in the prevention of neural tube defects and in limiting methotrexate side effects, and may reduce the risk of colorectal cancer. Folate is a critical vitamin in determining plasma homocysteine levels, which in turn is a major risk factor for cardiovascular diseases. The results of large clinical trials with dietary supplementation of folic acid, vitamin B12 and vitamin B6 have shown that this homocysteine-lowering therapy is effective in the secondary prevention of non-fatal strokes, but had no effect in the prevention of fatal cardiovascular diseases. Hyperhomocysteinemia has also been reported in age-related neurological conditions with cognitive impairment (e.g. dementia), and psychiatric disorders such as depression. Elevated homocysteine levels are frequent in patients with chronic immune-mediated disorders including rheumatoid arthritis, systemic lupus erythematosus, chronic plaque psoriasis and psoriatic arthritis, which have in common a tendency to an accelerated atherosclerosis leading to increased deaths from cardiovascular events. Folic acid supplementation appears as a reasonable therapeutic option in patients affected by chronic inflammatory skin diseases, such as moderate to severe psoriasis; in particular, those with concomitant hyperhomocysteinemia, low plasma folate and additional cardiovascular risk factors.

Effect of folic or folinic acid supplementation on methotrexate-associated safety and efficacy in inflammatory disease: a systematic review

BACKGROUND

Methotrexate is a folic acid antagonist widely used for the treatment of inflammatory disorders for more than 50 years. Methotrexate is a standard systemic therapy for severe psoriasis and rheumatoid arthritis. Folic acid supplementation has been advocated to limit the toxicity of methotrexate on blood cells, gastrointestinal tract and liver. However, there is still controversy regarding the usefulness of folic acid supplementation.

OBJECTIVES

We sought to assess the evidence for the efficacy of folic acid supplementation in patients treated with methotrexate for inflammatory diseases. We also investigated whether folic acid supplementation may decrease the efficacy of methotrexate.

METHODS

Cochrane and MEDLINE databases were systematically searched. Randomized controlled trials in patients treated with methotrexate for rheumatoid arthritis or psoriasis with or without arthritis were included. Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent researchers. We selected double-blind randomized placebo-controlled trials. Analysis was performed for each subgroup of side-effects: gastrointestinal, mucocutaneous, haematological and hepatic.

RESULTS

Six randomized controlled trials met the inclusion criteria, with a total sample of 648 patients. There were 257 patients in the placebo group, 198 patients treated with folic acid, and 193 patients treated with folinic acid. The statistical analysis showed a significant reduction of 35.8% of hepatic side-effects induced by methotrexate for patients with supplementation with folic or folinic acid (95% confidence interval -0.467 to -0.248). There was no statistical difference for mucocutaneous and gastrointestinal side-effects although there was a trend in favour of supplementation. The effect of supplementation on haematological side-effects could not be assessed accurately due to a low incidence of these events in the population studied. We were unable to analyse the effect of supplementation on the effectiveness of methotrexate, as markers of activity used in each study were not comparable.

CONCLUSIONS

Supplementation with folic acid is an effective measure to reduce hepatic adverse effects associated with methotrexate treatment. There is no difference between folinic acid and folic acid, but the lower cost of the latter promotes its use.

Methotrexate vs. ciclosporin in psoriasis: effectiveness, quality of life and safety. A randomized controlled trial

BACKGROUND

When this study was initiated, no previous studies comparing methotrexate and ciclosporin for moderate to severe plaque psoriasis had been performed.

OBJECTIVES

To compare the effectiveness, quality of life and side-effects of methotrexate and ciclosporin treatments in a context reflecting normal clinical practice.

METHODS

Eighty-four patients with moderate to severe plaque psoriasis were randomized to treatment with methotrexate or ciclosporin for 12 weeks. The primary outcome was the Psoriasis Area and Severity Index (PASI). The secondary outcome was quality of life, measured by the Dermatology Life Quality Index (DLQI) and the 36-item Short Form Health Survey (SF-36). A visual analogue scale (VAS) was used for patients' assessment.

RESULTS

Sixty-eight patients started treatment and were included in the analysis. Dropout before initiation of treatment was higher in the ciclosporin group. Mean PASI change from baseline at 12 weeks was 58% in the methotrexate group and 72% in the ciclosporin group, showing ciclosporin to be more effective than methotrexate. Improvement of the VAS score was higher in the ciclosporin group. The methotrexate group showed a greater improvement in the subscale Physical Functioning of the SF-36. No significant difference between the groups was found for DLQI.

CONCLUSIONS

Treatment with methotrexate or ciclosporin for chronic plaque psoriasis brings satisfactory disease control, improved quality of life and tolerable side-effects. A statistically significant difference in effectiveness between treatment groups was recorded, showing ciclosporin to be more effective than methotrexate in a short-term perspective.

Dermatologists’ Adherence to the Guideline of the Dutch Society of Dermatology and Venereology with Respect to the Treatment with Methotrexate for Severe Chronic Plaque Psoriasis: Results from a Dutch Survey

BACKGROUND

In 2003, the Dutch guideline 'Photo(chemo) therapy and systemic therapy for severe chronic plaque psoriasis' was established.

OBJECTIVES

To document how closely this guideline is followed in clinical practice with respect to the methotrexate (MTX) treatment and to formulate recommendations to adjust the guideline.

METHODS

A survey was conducted among Dutch dermatologists and residents in dermatology. The questionnaire assessed the knowledge of and the adherence to the guideline with respect to MTX treatment.

RESULTS

Fifty percent of the contacted dermatologists/residents responded. Fifty-two percent follow the guideline with respect to MTX. Liver biopsy and the frequency of blood investigations cause a discrepancy between guideline and reality. There is a lack of consensus between guidelines of the different specialisms concerning liver biopsy.

CONCLUSION

The need for liver biopsies in combination with the frequent check-ups and the lack of consensus between rheumatologists, hepatologists and dermatologists seem to restrict the adherence to the guideline.

Dermatologists’ Views and Opinions about Photo(chemo)therapy and Conventional Systemic Psoriasis Therapies: Results from a Belgian Survey

BACKGROUND

Experts' opinions about old and new psoriasis therapies are well documented.

OBJECTIVES

To document the views and opinions of a large, diverse group of dermatologists about psoriasis treatment.

PARTICIPANTS/METHODS

A survey was conducted among Belgian dermatologists. In addition to demographic and professional characteristics, the questionnaire assessed the self-rated level of experience, frequency of use, preference and considerations regarding UVB, PUVA, methotrexate (MTX), cyclosporin (CsA) and acitretin. Multivariate logistic regression analyses were performed to investigate predictors of these dermatologist-based outcomes.

RESULTS

Of the 628 contacted dermatologists, 310 responded (response rate of 49.3%). The dermatologists were significantly more experienced with photo(chemo)therapy than with systemic agents (p < or = 0.02); about half reported none or little experience with MTX and CsA. Also, photo(chemo)therapies were significantly more frequently used than systemic drugs (p < or = 0.01). In the last year, almost 40% had not used and less than 10% had used MTX or CsA more than 10 times. Despite the limitations of PUVA, it was preferred to UVB, followed by acitretin (+/- phototherapy), and MTX and CsA were considered final options by most dermatologists. After adjusting for confounding variables, age, years in practice, seeing and treating more patients, residency programme and/or access to UV therapy were significantly associated with limited experience, regular use and/or preference of studied therapies.

CONCLUSION

Either a substantial proportion of the dermatologists does not need or wish to use conventional systemic psoriasis therapies or they may need better and more uniform training during and after their residency. This may improve patient care and patient selection for other treatments.

Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial

BACKGROUND

The value of folate supplementation in methotrexate (MTX)-treated patients remains controversial.

OBJECTIVES

To determine the effect of folic acid (FA) on the efficacy of MTX and the frequency of side-effects associated with MTX therapy.

METHODS

A 12-week double-blind clinical trial was conducted in patients with psoriasis stable on their long-term MTX doses but not receiving FA. They were randomized into two arms of either FA 5 mg or placebo daily. MTX doses were not changed throughout the study. Patients were monitored every 3 weeks by the same observer. Assessments included Psoriasis Area and Severity Index (PASI), a visual analogue scale (VAS) of patients' perception of their psoriasis severity and the Dermatology Life Quality Index (DLQI). Adverse events were systematically recorded. Haematological and biochemical monitoring was performed.

RESULTS

Twenty-two patients with psoriasis were recruited. Age, sex and weekly MTX doses were similar in both groups. All 22 patients completed the study. The mean PASI in the FA group increased from 6.4 at baseline to 10.8 at 12 weeks. In the placebo group the mean PASI fell from 9.8 at baseline to 9.2 at 12 weeks. The mean change from baseline in the FA group was 4.4 vs. -0.6 in the placebo group (P < 0.05). Similar trends were observed in the changes in VAS and in the DLQI and differences between the groups were significant for both these parameters (P < 0.05). Few adverse effects were reported.

CONCLUSIONS

This study suggests that supplementation with FA during long-term MTX treatment reduces the efficacy of MTX in the control of psoriasis. Due to the relatively small sample size and short duration of this study, no conclusions can be drawn regarding the possibility that FA may reduce the side-effects of MTX.