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Taylor DR, Stone C. Current issues with procollagen III N-terminal peptide assay performance relevant to 2016 British Association for Dermatologist methotrexate-monitoring guidance. Clin Exp Dermatol 2023; 48:1378-1379. [PMID: 37616532 DOI: 10.1093/ced/llad287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 08/26/2023]
Abstract
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.
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Affiliation(s)
- David R Taylor
- Department of Clinical Biochemistry (Synnovis), King's College Hospital NHS Foundation Trust, London, UK
| | - Colin Stone
- Department of Clinical Biochemistry (Synnovis), King's College Hospital NHS Foundation Trust, London, UK
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2
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van Huizen AM, Sikkel R, Caron AGM, Menting SP, Spuls PI. Methotrexate Dosing Regimen for Plaque-type Psoriasis: An Update of a Systematic Review. J DERMATOL TREAT 2022; 33:3104-3118. [PMID: 36043844 DOI: 10.1080/09546634.2022.2117539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Astrid M van Huizen
- Amsterdam UMC, location University of Amsterdam, Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
| | - Rosie Sikkel
- Amsterdam UMC, location University of Amsterdam, Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anouk G M Caron
- Amsterdam UMC, location University of Amsterdam, Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
| | - Stef P Menting
- OLVG hospital, Department of Dermatology, Amsterdam, the Netherlands
| | - Phyllis I Spuls
- Amsterdam UMC, location University of Amsterdam, Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Meibergdreef 9, Amsterdam, the Netherlands
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3
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Sobolev VV, Soboleva AG, Denisova EV, Pechatnikova EA, Dvoryankova E, Korsunskaya IM, Mezentsev A. Proteomic Studies of Psoriasis. Biomedicines 2022; 10:biomedicines10030619. [PMID: 35327421 PMCID: PMC8945259 DOI: 10.3390/biomedicines10030619] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 02/05/2023] Open
Abstract
In this review paper, we discuss the contribution of proteomic studies to the discovery of disease-specific biomarkers to monitor the disease and evaluate available treatment options for psoriasis. Psoriasis is one of the most prevalent skin disorders driven by a Th17-specific immune response. Although potential patients have a genetic predisposition to psoriasis, the etiology of the disease remains unknown. During the last two decades, proteomics became deeply integrated with psoriatic research. The data obtained in proteomic studies facilitated the discovery of novel mechanisms and the verification of many experimental hypotheses of the disease pathogenesis. The detailed data analysis revealed multiple differentially expressed proteins and significant changes in proteome associated with the disease and drug efficacy. In this respect, there is a need for proteomic studies to characterize the role of the disease-specific biomarkers in the pathogenesis of psoriasis, develop clinical applications to choose the most efficient treatment options and monitor the therapeutic response.
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Affiliation(s)
- Vladimir V. Sobolev
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
- Correspondence: (V.V.S.); (A.M.)
| | - Anna G. Soboleva
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
- Scientific Research Institute of Human Morphology, 117418 Moscow, Russia
| | - Elena V. Denisova
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
- Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, 119071 Moscow, Russia
| | - Eva A. Pechatnikova
- Department of Dermatology and Cosmetology, Pirogov Russian National Research Medical University, 117997 Moscow, Russia;
| | - Eugenia Dvoryankova
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
| | - Irina M. Korsunskaya
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
| | - Alexandre Mezentsev
- Centre of Theoretical Problems of Physico-Chemical Pharmacology, Russian Academy of Sciences, 119334 Moscow, Russia; (A.G.S.); (E.V.D.); (E.D.); (I.M.K.)
- Correspondence: (V.V.S.); (A.M.)
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4
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Adalimumab with methotrexate versus adalimumab monotherapy in psoriasis: First-year results of a single-blind randomized controlled trial. J Invest Dermatol 2022; 142:2375-2383.e6. [DOI: 10.1016/j.jid.2022.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/07/2023]
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5
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Identification of miR-199a-5p, miR-214-3p and miR-99b-5p as Fibrosis-Specific Extracellular Biomarkers and Promoters of HSC Activation. Int J Mol Sci 2021; 22:ijms22189799. [PMID: 34575957 PMCID: PMC8464755 DOI: 10.3390/ijms22189799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Liver fibrosis is characterized by the accumulation of extracellular matrix (ECM) resulting in the formation of fibrous scars. In the clinic, liver biopsies are the standard diagnostic method despite the potential for clinical complications. miRNAs are single-stranded, non-coding RNAs that can be detected in tissues, body fluids and cultured cells. The regulation of many miRNAs has been linked to tissue damage, including liver fibrosis in patients, resulting in aberrant miRNA expression/release. Experimental evidence also suggests that miRNAs are regulated in a similar manner in vitro and could thus serve as translational in vitro–in vivo biomarkers. In this work, we set out to identify and characterize biomarkers for liver fibrosis that could be used in vitro and clinically for research and diagnostic purposes. We focused on miRNAs released from hepatic 3D cultures exposed to methotrexate (MTX), which causes fibrosis, and acetaminophen (APAP), an acute hepatotoxicant with no clinically relevant association to liver fibrosis. Using a 3D in vitro model, we corroborated compound-specific responses as we show MTX induced a fibrotic response, and APAP did not. Performing miRNA-seq of cell culture supernatants, we identified potential miRNA biomarkers (miR-199a-5p, miR-214-3p, niRNA-125a-5p and miR-99b-5p) that were associated with a fibrotic phenotype and not with hepatocellular damage alone. Moreover, transfection of HSC with miR-199a-5p led to decreased expression of caveolin-1 and increased α-SMA expression, suggesting its role in HSC activation. In conclusion, we propose that extracellular miR-214-3p, miR-99b-5p, miR-125a-5p and specifically miR-199a-5p could contribute towards a panel of miRNAs for identifying liver fibrosis and that miR-199a-5p, miR-214-3p and miR-99b-5p are promoters of HSC activation.
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6
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Pourani MR, Abdollahimajd F, Zargari O, Shahidi Dadras M. Soluble biomarkers for diagnosis, monitoring, and therapeutic response assessment in psoriasis. J DERMATOL TREAT 2021; 33:1967-1974. [PMID: 34369253 DOI: 10.1080/09546634.2021.1966357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Psoriasis is an inflammatory disease associated with multiple comorbidities. Biomarkers for the assessment of psoriasis, its associated comorbidities, and the therapeutic response are not well characterized. A number of possible biomarkers for the diagnosis and monitoring of psoriasis have been proposed. PURPOSE To assess potential biomarkers for diagnosis of psoriasis, its associated comorbidities and response to treatment. METHODS We investigated medical databases from 2000 to 2021 and assessed relevant research. In this review, we evaluated the important biomarkers to help predict potential risk of psoriasis and disease activity (Beta-defensin-2, VEGF, Lipocalin-2, and YKL-40) and its possible inflammatory-related comorbidities like cardiovascular diseases (hs-CRP, GlycA, Psoriasin, IL-18, NT-proBNP, and Adipokines). In addition, we described the potential biomarkers for psoriatic arthritis (CXCL10, S100A8 and S100A9, and MicroRNA) and related manifestations such as enthesitis. Finally, we discussed novel markers for monitoring the response to specific treatments (HLA-C 06, PLC, TARC, NLR, and PLR) as well as potentially useful biomarkers for evaluation of therapy-associated adverse events (liver fibrosis-related markers). CONCLUSION A wide range of genetic, tissue and serum markers have been investigated in psoriasis; however, most of them are not used in routine clinical practice; and thorough physical examination along with the appropriate application of clinical scoring systems like Psoriasis Area and Severity Index (PASI) score are still of particular importance.
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Affiliation(s)
| | - Fahimeh Abdollahimajd
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Zargari
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Larsen JB, Knudsen CS, Parkner T. Procollagen III, N-terminal propeptide (PIIINP): establishment of reference intervals in Northern European adults and children using the MAGLUMI 800 chemiluminescence immunoassay. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:389-393. [PMID: 34057372 DOI: 10.1080/00365513.2021.1929444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Procollagen III, N-terminal propeptide (PIIINP) is used as a biomarker for increased collagen III-synthesis. Reference intervals have not been established for the MAGLUMI 800 chemiluminescence immunoassay (CLIA) in Northern European adults or in children. The present study aimed to establish age-specific reference intervals in a Northern European population. PIIINP serum levels were analysed in healthy blood donors 19-67 years (n = 240) and children 2-18 years (n = 420). Furthermore, we investigated total imprecision and stability at room temperature and at -20 °C and performed a method comparison between MAGLUMI 800 CLIA (Snibe Diagnostics, Shenzhen, China) and ADVIA Centaur CP (Siemens Healthcare Diagnostics, Tarrytown, NY,USA). PIIINP was influenced by age but not sex. We established the following reference intervals: 2-10 years, 18-62 µg/L; 11-18 years, 15-75 µg/L; 19-39 years, 15-55 µg/L; 40-67 years, 14-31 µg/L. Total imprecision for PIIINP on MAGLUMI 800 was acceptable with coefficients of variation of 4.9% in the low range and 9.4% in the high range. PIIINP was stable for 24 h at room temperature after centrifugation and for at least 7 months at -20 °C. MAGLUMI 800 yielded significantly higher PIIINP levels than ADVIA Centaur CP. In conclusion, we established age-specific reference intervals for PIIINP using MAGLUMI 800 CLIA in a large Danish cohort. Our results may be useful for other laboratories wishing to establish PIIINP on the same platform and may provide improved guidance for medical doctors treating both children and adults with fibrotic disorders.
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Affiliation(s)
| | | | - Tina Parkner
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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8
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Ozkok Akbulut T, Topaloglu Demir F, Oguz Topal I, Kara Polat A, Karadag AS, Aslan Kayiran M, Ozkur E, Kıvanc Altunay I. Drug survival and predictor factors for discontinuation of methotrexate in psoriasis: a real-life multicenter study. Int J Dermatol 2021; 60:1140-1147. [PMID: 34013975 DOI: 10.1111/ijd.15628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/12/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Drug survival is useful to evaluate long-term drug performance in daily practice. The aim of this study was to evaluate drug survival for methotrexate (MTX) monotherapy in patients with plaque-type psoriasis. METHODS We reviewed 3,512 follow-up charts of patients with psoriasis at five tertiary referral centers between January 2012 and January 2020. We analyzed baseline data and treatment outcomes of patients under MTX monotherapy. Drug survival was analyzed using Kaplan-Meier and Cox regression analyses. RESULTS Patients with psoriasis who were treated with MTX monotherapy were enrolled (N = 649). The median duration of drug survival was 15 months (95% CI: 13.2-16.8). The overall drug survival rate was 54.7%, 17.4%, and 8% after 1, 3, and 5 years, respectively. The main reasons for discontinuation were adverse effects (n = 209, 32.2%) and inefficacy (n = 105, 15.6%). Based on multivariate Cox regression analysis, the presence of nausea/vomiting (HR: 2.01, 95% CI: 1.49-2.71; P < 0.001) was observed as a statistically significant risk factor for drug discontinuation. Age over 50 years (HR: 0.68, 95% CI: 0.48-0.97; P = 0.03) and using MTX dose ≥15 mg/weekly were positive predictors for drug survival (HR: 0.72, 95% CI: 0.54-0.95; P = 0.02). CONCLUSIONS The average drug survival of MTX was 15 months. MTX is still the first-line treatment of moderate-to-severe plaque psoriasis, as highlighted in guidelines. To prevent premature discontinuation, physicians need to look at the response time of at least 16-24 weeks, especially when a stepwise dose increment is used. The presence of nausea/vomiting seemed to be associated with an approximately twofold risk of discontinuation.
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Affiliation(s)
- Tugba Ozkok Akbulut
- Department of Dermatology and Venereology, University of Health Sciences, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Filiz Topaloglu Demir
- Department of Dermatology and Venereology, Faculty of Medicine, University of Medipol, Istanbul, Turkey
| | - Ilteris Oguz Topal
- Department of Dermatology and Venereology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Asude Kara Polat
- Department of Dermatology and Venereology, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Ayse Serap Karadag
- Department of Dermatology and Venereology, Faculty of Medicine, University of Medeniyet, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Melek Aslan Kayiran
- Department of Dermatology and Venereology, Faculty of Medicine, University of Medeniyet, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Ezgi Ozkur
- Department of Dermatology and Venereology, University of Health Sciences, Sisli Training and Research Hospital, Istanbul, Turkey
| | - Ilknur Kıvanc Altunay
- Department of Dermatology and Venereology, University of Health Sciences, Sisli Training and Research Hospital, Istanbul, Turkey
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9
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Wang Z, Huang Y, Nossent H, Chan JJ, Adams LA, Joseph J, Cheng W, Garas G, MacQuillan G, Jeffrey GP. Hepascore predicts liver outcomes and all-cause mortality in long-term methotrexate users: A retrospective cohort study. JGH OPEN 2020; 4:1211-1216. [PMID: 33319058 PMCID: PMC7731826 DOI: 10.1002/jgh3.12430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 12/24/2022]
Abstract
Background and aim Methotrexate (MTX) is routinely used for immunological disorders, and its long‐term use is associated with hepatotoxicity. The aim of this study was to investigate whether a serum liver fibrosis test (Hepascore) predicted the risk of adverse liver‐related outcomes and mortality. Methods A total of 92 patients in Western Australia who had a long‐term MTX intake history,from 2004 to 2016, were recruited and followed up from the first Hepascore to death or end of the study. Clinical data, all deaths, and liver‐related outcomes (liver‐related death and decompensation) were obtained from hospital, PathWest, and WA Data Linkage Unit databases. Results Nine deaths and four adverse liver‐related outcomes occurred during the follow up of 354 person‐years. The 5‐year survival was 86.1%. The liver‐related outcome free survival was 95.6%. Baseline Hepascore ≥0.84 was associated with advanced fibrosis on liver biopsy (P = 0.025). A baseline Hepascore ≥0.84 was significantly associated with higher risks for adverse liver‐related outcomes (P < 0.001) and all‐cause mortality (P = 0.001). Cox regression demonstrated that only baseline Hepascore ≥0.84 was independently associated with the increased risk of all‐cause mortality (7.91 [1.52–41.29], P = 0.014). Moreover, any Hepascore ≥0.84 found during follow up was independently associated with the increased risk of all‐cause mortality (86.18 [4.03–1844.83], P = 0.007). Conclusions This study demonstrated the potential importance of Hepascore monitoring in long‐term MTX users. Patients with a Hepascore higher than 0.84 at any stage had increased mortality, but further studies are required to confirm this finding.
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Affiliation(s)
- Zhengyi Wang
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Yi Huang
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Hans Nossent
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of RheumatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Jonathan J Chan
- Department of DermatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Leon A Adams
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - John Joseph
- Department of BiochemistryPathWest Laboratory MedicinePerthWestern AustraliaAustralia
| | - Wendy Cheng
- Department of Gastroenterology and HepatologyRoyal Perth HospitalPerthWestern AustraliaAustralia
| | - George Garas
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Gerry MacQuillan
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Gary P Jeffrey
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
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10
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Balak DMW, Gerdes S, Parodi A, Salgado-Boquete L. Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature. Dermatol Ther (Heidelb) 2020; 10:589-613. [PMID: 32529393 PMCID: PMC7367959 DOI: 10.1007/s13555-020-00409-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Deepak M W Balak
- Department of Dermatology, LangeLand Ziekenhuis, Zoetermeer, the Netherlands.
| | - Sascha Gerdes
- Department of Dermatology, Psoriasis-Center, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Aurora Parodi
- DiSSal Section of Dermatology, University of Genoa-Ospedale-Policlinico San Martino IRCCS, Genoa, Italy
| | - Laura Salgado-Boquete
- Department of Dermatology, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
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11
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Anvari B. Methotrexate Hepatotoxicity in Rheumatoid Arthritis: An Analysis of the Physicians’ Policy. Curr Rheumatol Rev 2020; 16:67-73. [DOI: 10.2174/1573397115666190618124407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
Background::
Methotrexate hepatotoxicity could be a reason for the discontinuation or
dose reduction in patients with Rheumatoid Arthritis (RA); however, the consequence of different
policies in this situation is unclear and the physicians need to know what would happen after their
decision.
Objective::
To demonstrate the consequence of multiple approaches towards transaminitis management
in patients with RA receiving Methotrexate (MTX).
Method::
Data were obtained from the previous work (2006) on 295 patients with RA undergoing
MTX treatment. Those who developed transaminitis at least one time were selected for this study.
Then, the physicians’ decisions regarding discontinuing, decreasing, or prescribing a fixed dose of
MTX along with the effect of each decision on the next liver enzyme were evaluated.
Results::
Strategies of decreasing dose or discontinuing MTX were adopted in 31.4% of patients
and prescribing fixed dose was done in 53.9% of patients, leading to 93% and 65% next enzyme
normalization, respectively. Thirty-four patients had definite MTX induced transaminitis and
55.9% of the physicians decided to decrease MTX dose for them, causing normalization of the next
enzyme in 83% of these patients. In contrast, continuing MTX, even with the same dose, in definite
MTX induced transaminitis cases led to consecutive enzyme elevations in 88.9% of these patients
(p=0.001).
Conclusion::
Normalization of liver enzymes was observed after decreasing dose or discontinuing
MTX, suggesting this policy as the best practice for the management of MTX induced transaminitis.
However, the trend to improvement, despite the type of physicians’ decision, was observed.
This trend was not found in definite MTX induced transaminitis, revealing the prominence of the
physician’s policy in this situation.
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Affiliation(s)
- Bita Anvari
- Department of Internal Medicine, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
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12
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Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol 2020; 82:1445-1486. [PMID: 32119894 DOI: 10.1016/j.jaad.2020.02.044] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. In this guideline, we focus the discussion on systemic, nonbiologic medications for the treatment of this disease. We provide detailed discussion of efficacy and safety for the most commonly used medications, including methotrexate, cyclosporine, and acitretin, and provide recommendations to assist prescribers in initiating and managing patients on these treatments. Additionally, we discuss newer therapies, including tofacitinib and apremilast, and briefly touch on a number of other medications, including fumaric acid esters (used outside the United States) and therapies that are no longer widely used for the treatment of psoriasis (ie, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus).
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Affiliation(s)
| | - Joel M Gelfand
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Kelly M Cordoro
- Department of Dermatology, University of California, San Francisco School of Medicine, San Diego, California
| | | | | | | | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | | | | | - Matthew Kiselica
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | | | - Neil J Korman
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason Lichten
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Nehal N Mehta
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Arun L Pathy
- Colorado Permanente Medical Group, Centennial, Colorado
| | | | | | - Reena N Rupani
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Bruce E Strober
- Central Connecticut Dermatology, Cromwell, Connecticut; Yale University, New Haven, Connecticut
| | - Elliot B Tapper
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Emily B Wong
- San Antonio Uniformed Services Health Education Consortium, Joint-Base San Antonio, Texas
| | - Jashin J Wu
- Dermatology Research and Education Foundation, Irvine, California
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Mazaud C, Fardet L. Daily practices regarding safety monitoring of low-dose methotrexate and comparison to guidelines: A population-based cohort study. Therapie 2019; 76:425-433. [PMID: 32354461 DOI: 10.1016/j.therap.2019.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/28/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe daily practices regarding safety monitoring of methotrexate prescribed at low-(i.e.≤30mg/week). To identify determinants of these practices. To assess association between monitoring and early methotrexate discontinuation. METHODS Population-based cohort study using the French claims database échantillongénéralistedebénéficiaires (EGB) over the period 2009-2015. Incident methotrexate users were included. The pre-treatment and post-treatment monitoring prescribed to these patients was analyzed. Determinants of monitoring were identified using a logistic regression model. Association between monitoring and early methotrexate discontinuation was assessed using Cox proportional-hazards model. RESULTS During the study period, 615924 individuals had data in the EGB and 2472 (0.40%) were incident methotrexate users (63.3% women; mean age: 54.7±17.8 years; mean weekly dosage: 13.0±5.3mg). Among these incident users, only 50-70% had an albumin testing (67.0%); HIV (49.7%), hepatitis B (54.8%) or C (55.0%) serology; or chest X-ray (57.4%) within the year before initiating methotrexate. Only 65.7% had a least one CBC, transaminase and urea-creatinine testing combined within the three months before initiation. During the first three months of exposure, the median number of CBC, transaminase and urea-creatinine testing was 2 [1-4], 2 [1-4], and 2 [1-3], respectively. The monitoring modalities depend more on prescriber characteristics than on patient or treatment characteristics. There was a significant positive association between frequency of monitoring during exposure and early methotrexate discontinuation. CONCLUSION Monitoring of patients prescribed low-dose methotrexate is much less frequent than recommended. Frequent monitoring is associated with early methotrexate discontinuation.
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Affiliation(s)
- Canelle Mazaud
- Service de dermatologie, hôpital Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Laurence Fardet
- Service de dermatologie, hôpital Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; EA 7379, EpiDermE, université Paris Est Créteil (UPEC), 94010 Créteil, France.
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15
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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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16
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Gordon KB, Betts KA, Sundaram M, Signorovitch JE, Li J, Xie M, Wu EQ, Okun MM. Poor early response to methotrexate portends inadequate long-term outcomes in patients with moderate-to-severe psoriasis: Evidence from 2 phase 3 clinical trials. J Am Acad Dermatol 2017; 77:1030-1037. [PMID: 28993007 DOI: 10.1016/j.jaad.2017.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 08/02/2017] [Accepted: 08/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most methotrexate-treated psoriasis patients do not achieve a long-term PASI75 (75% reduction from baseline Psoriasis Area and Severity Index score) response. Indications of nonresponse can be apparent after only 4 weeks of treatment. OBJECTIVE To develop a prediction rule to identify patients unlikely to respond adequately to methotrexate. METHODS Patient-level data from CHAMPION (NCT00235820, N = 110) was used to construct a prediction model for week 16 PASI75 by using patient baseline characteristics and week 4 PASI25. A prediction rule was determined on the basis of the sensitivity and specificity and validated in terms of week 16 PASI75 response in an independent validation sample from trial M10-255 (NCT00679731, N = 163). RESULTS PASI25 achievement at week 4 (odds ratio = 8.917) was highly predictive of response with methotrexate at week 16. Patients with a predicted response probability <30% were recommended to discontinue methotrexate. The rates of week 16 PASI75 response were 65.8% and 21.1% (P < .001) for patients recommended to continue and discontinue methotrexate, respectively. LIMITATIONS The CHAMPION trial excluded patients previously treated with biologics, and the M10-255 trial had no restrictions. CONCLUSION A prediction rule was developed and validated to identify patients unlikely to respond adequately to methotrexate. The rule indicates that 4 weeks of methotrexate might be sufficient to predict long-term response with limited safety risk.
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Affiliation(s)
| | | | | | | | - Junlong Li
- Analysis Group Inc, Boston, Massachusetts
| | - Meng Xie
- Analysis Group Inc, Boston, Massachusetts
| | - Eric Q Wu
- Analysis Group Inc, Boston, Massachusetts
| | - Martin M Okun
- AbbVie Inc, North Chicago, Illinois; Fort HealthCare, Fort Atkinson, Wisconsin
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17
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Mazaud C, Fardet L. Relative risk of and determinants for adverse events of methotrexate prescribed at a low dose: a systematic review and meta-analysis of randomized placebo-controlled trials. Br J Dermatol 2017; 177:978-986. [PMID: 28182264 DOI: 10.1111/bjd.15377] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 12/13/2022]
Abstract
Low-dose (i.e. ≤ 30 mg per week) methotrexate is widely prescribed by dermatologists. However, there is limited evidence-based information regarding the relative risk of and determinants for adverse events associated with this treatment. The aims of this review were to assess the relative risk of and the determinants for adverse events associated with low-dose methotrexate exposure. A systematic review was undertaken using the MEDLINE, Embase and CENTRAL databases. Randomized controlled trials comparing low-dose methotrexate with placebo were eligible. Random effect meta-analyses were conducted to assess the risk ratios (RRs) of adverse events associated with methotrexate exposure. Subgroup analyses and random effect meta-regressions were performed to examine the determinants of adverse events. In total, 68 trials (6938 participants) were included. Compared with placebo, low-dose methotrexate slightly increased the risk of adverse events (mean number per individual: 1·78 ± 2·00 in the methotrexate group, 1·53 ± 1·89 in the placebo group; P < 0·001), including nausea/vomiting, elevated transaminase levels, mucosal ulcerations, leucopenia, thrombopenia and infectious events, but not the risk of serious adverse events or death. Low-dose methotrexate also increased the number of withdrawals from studies because of adverse events [RR 1·32 (1·13-1·53)]. The concomitant prescription of folic/folinic acid was associated with a significant lower risk of any adverse events, and methotrexate prescribed orally was associated with a higher risk of abdominal pain than when prescribed subcutaneously or by intramuscular injection. On the other hand, the risk of adverse events did not increase with the weekly dose or with duration of exposure. Similar studies comparing methotrexate with other systemic/biological treatments are needed.
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Affiliation(s)
- C Mazaud
- Service de Dermatologie, Hôpital Henri Mondor, Créteil, France
| | - L Fardet
- Service de Dermatologie, Hôpital Henri Mondor, Créteil, France.,EA 7379, EpiDermE, UPEC Université Paris Est Créteil, Créteil, France
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18
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Warren RB, Weatherhead SC, Smith CH, Exton LS, Mohd Mustapa MF, Kirby B, Yesudian PD. British Association of Dermatologists' guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2017; 175:23-44. [PMID: 27484275 DOI: 10.1111/bjd.14816] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 12/25/2022]
Affiliation(s)
- R B Warren
- The Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M6 8HD, U.K
| | - S C Weatherhead
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - B Kirby
- St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - P D Yesudian
- Glan Clwyd Hospital, Sarn Lane, Rhyl, LL18 5UJ, U.K
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19
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Prestigiacomo V, Weston A, Messner S, Lampart F, Suter-Dick L. Pro-fibrotic compounds induce stellate cell activation, ECM-remodelling and Nrf2 activation in a human 3D-multicellular model of liver fibrosis. PLoS One 2017; 12:e0179995. [PMID: 28665955 PMCID: PMC5493342 DOI: 10.1371/journal.pone.0179995] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 06/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Currently most liver fibrosis research is performed in vivo, since suitable alternative in vitro systems which are able to recapitulate the cellular events leading to liver fibrosis are lacking. Here we aimed at generating a system containing cells representing the three key players of liver fibrosis (hepatocyte, Kupffer cells and stellate cells) and assess their response to pro-fibrotic compounds such as TGF-β1, methotrexate (MTX) and thioacetamide (TAA). Methods Human cell lines representing hepatocytes (HepaRG), Kupffer cell (THP-1 macrophages) and stellate cells (hTERT-HSC) were co-cultured using the InSphero hanging drop technology to generate scaffold-free 3D microtissues, that were treated with pro-fibrotic compounds (TGF-β1, MTX, TAA) for up to 14 days. The response of the microtissues was evaluated by determining the expression of cytokines (TNF-α, TGF-β1 and IL6), the deposition and secretion of ECM proteins and induction of gene expression of fibrosis biomarkers (e.g. αSMA). Induction of Nrf2 and Keap1, as key player of defence mechanism, was also evaluated. Results We could demonstrate that the multicellular 3D microtissue cultures could be maintained in a non-activated status, based on the low expression levels of activation markers. Macrophages were activated by stimulation with LPS and hTERT-HSC showed activation by TGF-β1. In addition, MTX and TAA elicited a fibrotic phenotype, as assessed by gene-expression and protein-deposition of ECM proteins such as collagens and fibronectin. An involvement of the antioxidant pathway upon stimulation with pro-fibrotic compounds was also observed. Conclusion Here, for the first time, we demonstrate the in vitro recapitulation of key molecular and cellular events leading to liver fibrosis: hepatocellular injury, antioxidant defence response, activation of Kupffer cells and activation of HSC leading to deposition of ECM.
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Affiliation(s)
- Vincenzo Prestigiacomo
- University of Applied Sciences Northwestern Switzerland, School of Life Sciences, Muttenz, Switzerland
- University of Basel, Department of Pharmaceutical Sciences, Basel, Switzerland
- * E-mail:
| | - Anna Weston
- University of Applied Sciences Northwestern Switzerland, School of Life Sciences, Muttenz, Switzerland
| | - Simon Messner
- InSphero AG, Schlieren, Canton of Zürich, Switzerland
| | - Franziska Lampart
- University of Applied Sciences Northwestern Switzerland, School of Life Sciences, Muttenz, Switzerland
| | - Laura Suter-Dick
- University of Applied Sciences Northwestern Switzerland, School of Life Sciences, Muttenz, Switzerland
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20
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Norona LM, Nguyen DG, Gerber DA, Presnell SC, LeCluyse EL. Editor's Highlight: Modeling Compound-Induced Fibrogenesis In Vitro Using Three-Dimensional Bioprinted Human Liver Tissues. Toxicol Sci 2016; 154:354-367. [PMID: 27605418 DOI: 10.1093/toxsci/kfw169] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Compound-induced liver injury leading to fibrosis remains a challenge for the development of an Adverse Outcome Pathway useful for human risk assessment. Latency to detection and lack of early, systematically detectable biomarkers make it difficult to characterize the dynamic and complex intercellular interactions that occur during progressive liver injury. Here, we demonstrate the utility of bioprinted tissue constructs comprising primary hepatocytes, hepatic stellate cells, and endothelial cells to model methotrexate- and thioacetamide-induced liver injury leading to fibrosis. Repeated, low-concentration exposure to these compounds enabled the detection and differentiation of multiple modes of liver injury, including hepatocellular damage, and progressive fibrogenesis characterized by the deposition and accumulation of fibrillar collagens in patterns analogous to those described in clinical samples obtained from patients with fibrotic liver injury. Transient cytokine production and upregulation of fibrosis-associated genes ACTA2 and COL1A1 mimics hallmark features of a classic wound-healing response. A surge in proinflammatory cytokines (eg, IL-8, IL-1β) during the early culture time period is followed by concentration- and treatment-dependent alterations in immunomodulatory and chemotactic cytokines such as IL-13, IL-6, and MCP-1. These combined data provide strong proof-of-concept that 3D bioprinted liver tissues can recapitulate drug-, chemical-, and TGF-β1-induced fibrogenesis at the cellular, molecular, and histological levels and underscore the value of the model for further exploration of compound-specific fibrogenic responses. This novel system will enable a more comprehensive characterization of key attributes unique to fibrogenic agents during the onset and progression of liver injury as well as mechanistic insights, thus improving compound risk assessment.
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Affiliation(s)
- Leah M Norona
- Curriculum in Toxicology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599 .,Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, North Carolina 27599.,The Institute for Drug Safety Sciences, Research Triangle Park, North Carolina 27709
| | - Deborah G Nguyen
- Research and Development, Organovo, Inc, San Diego, California 92121
| | - David A Gerber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599
| | - Sharon C Presnell
- Research and Development, Organovo, Inc, San Diego, California 92121
| | - Edward L LeCluyse
- Curriculum in Toxicology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599.,The Institute for Drug Safety Sciences, Research Triangle Park, North Carolina 27709
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Protective Role of Silymarin on Hepatic and Renal Toxicity Induced by MTX Based Chemotherapy in Children with Acute Lymphoblastic Leukemia. Mediterr J Hematol Infect Dis 2016; 8:e2016043. [PMID: 27648206 PMCID: PMC5016017 DOI: 10.4084/mjhid.2016.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/29/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND ALL is the most common childhood malignancy. The children with ALL are treated with methotrexate (MTX) based chemotherapy protocols. MTX causes unpredictable serious hepatic and renal side effects. Silymarin has antioxidant and anti-inflammatory activities and stimulates tissue regeneration. This study aims to evaluate the protective effects of Silymarin on MTX-based chemotherapy-induced Hepatic and renal toxicity in children with ALL. PATIENTS AND METHODS 80 children with newly diagnosed ALL were enrolled in the study. They were randomly divided into two groups. Group I included 40 children with ages ranging from 4-13 years and the mean age of 6.85± 2.89 years, who received Silymarin 420 mg/day in 3 divided doses for one week after each MTX dose. Group II included 40 children, with ages ranging from 4-12 years and the mean age of 7.30±2.6 years, who received placebo for one week after MTX therapy. For all patients liver functions including serum bilirubin, total proteins, albumin, globulin and albumin-globulin ratio, alkaline phosphatase, ALT and AST, prothrombin time and activity and renal functions including blood urea and serum creatinine, serum cystatin C and urinary N-acetyl-beta-D-glucosaminidase were done to assess hepatic and renal toxicity before and after chemotherapy. RESULTS There were no significant differences between group I and II as regard liver and renal functions before chemotherapy. After chemotherapy, there were significantly higher values of ALT and AST and alkaline phosphatase, and significantly lower Prothrombin activity in group II compared with group I. No significant differences between group I and II were found in total bilirubin, serum protein, and albumin levels. There was significantly lower blood urea, serum creatinine, and cystatin C and urinary N-acetyl-beta-D-glucosaminidase in group I compared with group II. CONCLUSION Silymarin improved some hepatic and renal functions in children with ALL who received MTX-based chemotherapy protocols. RECOMMENDATIONS Extensive multicenter studies could be recommended to prove the hepatic and renal protective effects of Silymarin in patients with ALL who received MTX-based chemotherapy protocols.
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Comparative efficacy and incremental cost per responder of methotrexate versus apremilast for methotrexate-naïve patients with psoriasis. J Am Acad Dermatol 2016; 75:740-746. [PMID: 27476973 DOI: 10.1016/j.jaad.2016.05.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND To our knowledge, no clinical trials directly compare apremilast with methotrexate (the standard of care for initial systemic treatment of psoriasis). OBJECTIVE We sought to compare apremilast's relative efficacy with that of methotrexate for moderate to severe psoriasis. METHODS An anchor-based indirect comparison was conducted for 75% improvement in Psoriasis Area and Severity Index score from baseline to week 16 (PASI 75) rates for systemic-naïve patients from Efficacy and Safety Trial Evaluating the Effects of apreMilast in psoriasis (ESTEEM) 1 and 2 (apremilast vs placebo) and Comparative study of HumirA vs. Methotrexate vs Placebo In psOriasis patieNts (CHAMPION) (adalimumab vs methotrexate vs placebo) trials. The difference-in-difference in PASI 75 response rates was calculated as the difference between the ESTEEM apremilast and placebo rates and the CHAMPION methotrexate versus placebo rates. Number needed to treat and incremental drug cost per responder were also estimated. RESULTS No statistically significant difference was found between apremilast and methotrexate in PASI 75 (risk difference 13.1%; 95% confidence interval -1.8% to 28.0%; P = .09). Number needed to treat with apremilast versus methotrexate to gain 1 additional PASI 75 responder was 7.6. Annual incremental drug cost of this responder was estimated at $187,888.33. LIMITATIONS Few trials compare systemic-naïve patients. Only direct medication costs were considered. CONCLUSIONS There was no statistical evidence of greater efficacy for apremilast versus methotrexate. The $187,888 incremental cost per PASI 75 may exceed what payers are willing to pay.
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23
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Rademaker M, Gupta M, Andrews M, Armour K, Baker C, Foley P, Gebauer K, George J, Rubel D, Sullivan J. The Australasian Psoriasis Collaboration view on methotrexate for psoriasis in the Australasian setting. Australas J Dermatol 2016; 58:166-170. [PMID: 27402434 DOI: 10.1111/ajd.12521] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
Abstract
The Australasian Psoriasis Collaboration reviewed methotrexate (MTX) in the management of psoriasis in the Australian and New Zealand setting. The following comments are based on expert opinion and a literature review. Low-dose MTX (< 0.4 mg/kg per week) has a slow onset of action and has moderate to good efficacy, together with an acceptable safety profile. The mechanism of action is anti-inflammatory, rather than immunosuppressive. For pretreatment, consider testing full blood count (FBC), liver and renal function, non-fasting lipids, hepatitis serology, HbA1c and glucose. Body mass index and abdominal circumference should also be measured. Optional investigations in at-risk groups include an HIV test, a QuantiFERON-TB Gold test and a chest X-ray. In patients without complications, repeat the FBC at 2-4 weeks, then every 3-6 months and the liver/renal function test at 3 months and then every 6 months. There is little evidence that a MTX test dose is of value. Low-dose MTX rarely causes clinically significant hepatotoxicity in psoriasis. Most treatment-emergent liver toxicity is related to underlying metabolic syndrome and non-alcoholic fatty liver disease or non-alcoholic steatohepatitis. Alcohol itself is not contraindicated, but should be limited to < 20 gm/day. [Correction added on 6 January 2017, after first online publication: '20 mg/day' has been corrected to '20 gm/day'.] Although MTX is a potential teratogen post-conception, there is little evidence for this pre-conception. MTX does not affect the quality of sperm. There is no evidence that MTX reduces healing, so there is no specific need to stop MTX peri-surgery. MTX may be used in combination with cyclosporine, acitretin, prednisone and anti-tumour necrosis factor biologics.
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Affiliation(s)
- Marius Rademaker
- Department of Dermatology, Waikato Clinical Campus, Auckland Medical School, Hamilton, New Zealand
| | - Monisha Gupta
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia.,Department of Medicine, UNSW, Sydney, New South Wales, Australia
| | - Megan Andrews
- Dermatology, Specialist Connect, Woolloongabba, Queensland, Australia
| | - Katherine Armour
- Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia.,Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia
| | - Chris Baker
- Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia.,Department of Medicine (Dermatology), The University of Melbourne, Melbourne, Victoria, Australia.,Department of Dermatology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Peter Foley
- Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia.,Department of Medicine (Dermatology), The University of Melbourne, Melbourne, Victoria, Australia.,Department of Dermatology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Kurt Gebauer
- Department of Dermatology, University of Western Australia, Perth, Western Australia, Australia
| | - Jacob George
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Diana Rubel
- Department of Dermatology, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,Department of Dermatology, Australian National University, Canberra, Australian Capital Territory, Australia
| | - John Sullivan
- Department of Medicine, UNSW, Sydney, New South Wales, Australia.,Dermatology, Holdsworth House Medical Practice, Sydney, New South Wales, Australia
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Brown AC. Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series. Food Chem Toxicol 2016; 107:472-501. [PMID: 27402097 DOI: 10.1016/j.fct.2016.07.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form. METHODS Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death. RESULTS Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract. CONCLUSION These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.
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Affiliation(s)
- Amy Christine Brown
- Department of Complementary and Alternative Medicine, John A. Burns School of Medicine, 651 Ilalo Street, MEB 223, University of Hawaii at Manoa, Honolulu, HI, 96813, USA.
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25
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Kaffenberger BH, Kaffenberger JA, Wong H, Jarjour W, Levin D, Bechtel MA. Magnetic resonance elastography and transient elastography as non-invasive analyses for liver fibrosis: can they obviate the need for liver biopsy in psoriasis patients treated with methotrexate? Int J Dermatol 2016; 54:752-6. [PMID: 26108262 DOI: 10.1111/ijd.12923] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The liver biopsy has been regarded as the reference standard method of monitoring hepatic fibrosis in psoriasis patients treated with methotrexate. It has also been subject to concerns over sampling error, internal and external variability, and potential for morbidity and mortality. During the past two decades, two imaging techniques, magnetic resonance elastography and transient elastography, have been developed and approved by the US Food and Drug Administration (FDA) for the assessment of hepatic fibrosis. Although high-quality, psoriasis-specific data are lacking, both methods have been shown to have outstanding efficacy in the detection of hepatic fibrosis, particularly the more advanced stages which may warrant the choice of a therapeutic alternative to methotrexate. Dermatologists should be aware of the availability of these tests and understand their limitations. Prospective studies in psoriasis and methotrexate management using these techniques are needed.
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Affiliation(s)
| | - Jessica A Kaffenberger
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Henry Wong
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Wael Jarjour
- Department of Rheumatology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Levin
- Department of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mark A Bechtel
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Tula E, Ergun T, Seckin D, Ozgen Z, Avsar E. Psoriasis and the liver: problems, causes and course. Australas J Dermatol 2016; 58:194-199. [PMID: 26916498 DOI: 10.1111/ajd.12460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 01/21/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND/OBJECTIVES Psoriasis patients have a higher risk of liver abnormalities such as non-alcoholic fatty liver disease (NAFLD), drug-induced hepatitis, alcoholic hepatitis and neutrophilic cholangitis, than the general population. Associated liver disease limits therapeutic options and necessitates careful monitoring. The aim of the study was to identify liver problems in psoriasis patients and to investigate the underlying causes as well as their course. METHODS The files of 518 psoriasis patients were retrospectively reviewed. Among these, 393 patients with relevant laboratory data were analysed for liver enzymes and their relation to the known risk factors for liver disease (obesity, diabetes mellitus, alcohol consumption, hepatotoxic medications, dyslipidemia, psoriatic arthritis and infectious hepatitis). RESULTS Among 393 patients, 24% and 0.8% developed liver enzyme abnormalities and cirrhosis, respectively. The most common factors associated with pathological liver enzymes were drugs (57%) and NAFLD (22%). Other rare causes were alcoholic hepatitis, viral hepatitis, neutrophilic cholangitis, autoimmune hepatitis and toxic hepatitis due to herbal therapy. Drug-induced liver enzyme abnormalities were reversible whereas in patients with NAFLD transaminases tended to fluctuate. One patient with herbal medicine-related cirrhosis died of sepsis. CONCLUSION Liver enzyme abnormalities are common in psoriasis patients and are mostly associated with drugs and NAFLD. Although most cases can be managed by avoiding hepatotoxic medications and close follow up, severe consequences like cirrhosis may develop.
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Affiliation(s)
- Elona Tula
- Department of Dermatology, Corlu Vatan Hospital, Tekirdag, Turkey
| | - Tulin Ergun
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Dilek Seckin
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Zuleyha Ozgen
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Erol Avsar
- Department of Gastroenterology, Marmara University School of Medicine, Istanbul, Turkey
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DeCoster E, Alves de Medeiros A, Bostoen J, Stockman A, van Geel N, Lapeere H, Lambert J. A multileveled approach in psoriasis assessment and follow-up: A proposal for a tailored guide for the dermatological practice. J DERMATOL TREAT 2015; 27:298-310. [PMID: 26671313 DOI: 10.3109/09546634.2015.1117566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Psoriasis is a complex and heterogeneous disease resulting from interactions between genetic, immunological, and environmental factors. To make the most optimal treatment decision, the dermatologist must therefore have a detailed overview of the patient's history and lifestyle. OBJECTIVES We sought to offer an overview of the various relevant aspects in clinical dermatological assessment of psoriasis patients, emphasizing the importance of a multidisciplinary and integrated clinical approach. METHODS We gathered information on psoriasis management and developed a tailored checklist covering all health-related aspects associated with psoriasis. RESULTS Demographics, personal and family history were elaborately described as well as drug history to discuss how they affect psoriasis management. Relevant patient information such as the vaccination status or cardiovascular profile were included in the checklist as well and treatment recommendations were adapted and updated in accordance with evidence-based literature. This checklist also emphasizes the importance of drug surveillance, proper follow-up and specialist referral, and why the dermatologist needs to address these health-related aspects when assessing psoriasis patients, going beyond optimal skin care. CONCLUSIONS Our comprehensive overview can be used as a consultation checklist for good clinical practice in psoriasis patient management and aid in treatment decision.
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Affiliation(s)
- Eveline DeCoster
- a Department of Dermatology , Ghent University Hospital , Ghent , Belgium and
| | | | - Jessica Bostoen
- a Department of Dermatology , Ghent University Hospital , Ghent , Belgium and
| | - Annelies Stockman
- b Department of Dermatology , AZ Sint Rembert Hospital , Torhout , Belgium
| | - Nanja van Geel
- a Department of Dermatology , Ghent University Hospital , Ghent , Belgium and
| | - Hilde Lapeere
- a Department of Dermatology , Ghent University Hospital , Ghent , Belgium and
| | - Jo Lambert
- a Department of Dermatology , Ghent University Hospital , Ghent , Belgium and
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Oliveira MDFSPD, Rocha BDO, Duarte GV. Psoriasis: classical and emerging comorbidities. An Bras Dermatol 2015; 90:9-20. [PMID: 25672294 PMCID: PMC4323693 DOI: 10.1590/abd1806-4841.20153038] [Citation(s) in RCA: 218] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/28/2013] [Indexed: 02/08/2023] Open
Abstract
Psoriasis is a chronic inflammatory systemic disease. Evidence shows an association
of psoriasis with arthritis, depression, inflammatory bowel disease and
cardiovascular diseases. Recently, several other comorbid conditions have been
proposed as related to the chronic inflammatory status of psoriasis. The
understanding of these conditions and their treatments will certainly lead to better
management of the disease. The present article aims to synthesize the knowledge in
the literature about the classical and emerging comorbidities related to
psoriasis.
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Screening and vaccinations in patients requiring systemic immunosuppression: an update for dermatologists. Am J Clin Dermatol 2015; 16:179-95. [PMID: 25854805 DOI: 10.1007/s40257-015-0124-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immunomodulatory agents are becoming an increasingly important tool in the dermatologist's armamentarium against autoimmune and auto-inflammatory conditions. This review addresses the guidelines for vaccination and screening studies prior to the initiation of immunomodulatory agents. Included are discussions of vaccination schedules, hepatitis vaccination and screening, tuberculosis screening, and specific screening recommendations for antimalarials, azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, tumor necrosis factor-α inhibitors, and newer medications like apremilast and tofacitinib.
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Hammerschmidt M, Mulinari Brenner F. Efficacy and safety of methotrexate in alopecia areata. An Bras Dermatol 2015; 89:729-34. [PMID: 25184911 PMCID: PMC4155950 DOI: 10.1590/abd1806-4841.20142869] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 09/09/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Alopecia areata is a chronic disorder of the hair follicles and nails, of unknown
etiology, with clear autoimmune components and genetic factors. Several
therapeutic options have been suggested; however, no treatment is able to modify
the disease course. Methotrexate is an immunosuppressant used in various
dermatoses and recently introduced as a therapeutic option for alopecia
areata. OBJECTIVES To evaluate the efficacy and safety of methotrexate in alopecia areata. METHODS In a retrospective, non-controlled study, we evaluated 31 patients with alopecia
areata in current or prior treatment with methotrexate to assess the therapeutic
response according to sex, age, pattern of alopecia areata, disease duration,
cumulative dose of methotrexate, use of systemic corticosteroids or other
treatments, and drug safety. RESULTS Regrowth greater than 50% was observed in 67.7% of patients, with the best
responses observed in those with <5 years of disease progression (79%), age
over 40 years (73.3%), male patients (72.8%), cumulative dose of methotrexate
1000-1500 mg, and multifocal alopecia areata (93%). Among patients receiving
systemic corticosteroids in combination with methotrexate, 77.3% had greater than
50% regrowth, compared with 44.4% in those who used methotrexate alone. The
therapeutic dose ranged from 10-25 mg/week. No patient had serious adverse
effects. Relapse was observed in 33.3% of patients with more than 50%
regrowth. CONCLUSION Methotrexate appears to be a promising and safe medication for the treatment of
severe alopecia areata when used alone or in combination with corticosteroids.
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Abstract
In the era of biologic therapies, methotrexate (MTX), a classic immunomodulator, is still the cornerstone of systemic treatment of psoriasis. MTX has been used for many years, achieving good responses with a good safety profile. However, only a few randomized clinical trials have been performed involving MTX, and most of the current evidence comes from pivotal studies of biologic drugs. The aim of this article is to make an extensive review of the MTX mechanism of action, pharmacokinetics, efficacy, safety and tolerability, especially focusing on the future perspective of this old drug and recent advances in the field of pharmacogenetics.
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Affiliation(s)
- Oriol Yélamos
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
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Parker S, Zhang AL, Zhang CS, Goodman G, Wen Z, Lu C, Xue CC. Oral granulated Chinese herbal medicine (YXBCM01) plus topical calcipotriol for psoriasis vulgaris: study protocol for a double-blind, randomized placebo controlled trial. Trials 2014; 15:495. [PMID: 25526951 PMCID: PMC4302103 DOI: 10.1186/1745-6215-15-495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/03/2014] [Indexed: 11/23/2022] Open
Abstract
Background Probably related to immune dysfunction, psoriasis vulgaris is a chronic, painful, disfiguring and disabling dermatological disease, carrying an increased risk of serious comorbidities. Current conventional therapies can be costly, show risks of side effects and have limited efficacy, with relapse common on treatment cessation. Chinese herbal medicine is effective in treating psoriasis vulgaris. However, any benefit of adding Chinese herbal medicine to conventional treatments when treating psoriasis vulgaris is yet to be determined. Methods/design This is a pilot randomized, placebo controlled, double-blinded trial. The pilot is primarily to determine the feasibility of undertaking a full size randomized trial. Thirty participants with psoriasis vulgaris and Psoriasis Area Severity Index (PASI) scores ≥7 and ≤12 will be included. Participants will be randomized (in a 1:1 ratio) to receive oral granulated Chinese herbal medicine YXBCM01 plus topical calcipotriol 0.005% or oral YXBCM01 placebo plus topical calcipotriol 0.005% treatment for 12 weeks, with a 12-week follow-up phase. The Chinese herbal medicine or placebo will be administered orally as dissolvable granules. The primary outcome measure will be PASI change (%) from baseline to the end of treatment phase. Secondary outcomes will include safety, key psoriasis-related cytokine changes (for example, IL12, IL17 and IL 23) during the entire trial and symptom relapse rates at the end of the follow-up phase. Discussion The study will evaluate the feasibility of a randomized controlled trial investigating combined conventional and Chinese herbal medicine therapy for psoriasis vulgaris. The ingredients of YXBCM01 were selected based on literature, the expert opinion on herbal medicine and pre-clinical evidence, for instance Chinese herbal medicine possesses anti-inflammatory or antiproliferative properties. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000493640.
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Affiliation(s)
| | | | | | | | | | - Chuanjian Lu
- School of Health Sciences, RMIT University, PO Box 71, Bundoora, Victoria 3083, Australia.
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The possibilities and principles of methotrexate treatment of psoriasis - the updated knowledge. Postepy Dermatol Alergol 2014; 31:392-400. [PMID: 25610355 PMCID: PMC4293394 DOI: 10.5114/pdia.2014.47121] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 11/10/2014] [Accepted: 11/25/2014] [Indexed: 12/14/2022] Open
Abstract
Psoriasis is a chronic multifactorial disease affecting 2–4% of the general population. Due to its nature, psoriasis has a negative impact on the quality of life of patients. Therefore, the choice of an appropriate and individually tailored treatment controlling the symptoms of the disorder is necessary and continues to be a challenge for dermatologists. Therapeutic modalities in psoriasis should on the one hand be effective and on the other hand present a good safety profile. Methotrexate (MTX) is one of treatment options for psoriasis and can be administered both as monotherapy or in combination schemes. The paper presents the current state of knowledge about the possible treatment of psoriatic patients with MTX according to contemporary guidelines.
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Dawwas MF, Aithal GP. End-stage methotrexate-related liver disease is rare and associated with features of the metabolic syndrome. Aliment Pharmacol Ther 2014; 40:938-48. [PMID: 25185870 DOI: 10.1111/apt.12912] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/19/2014] [Accepted: 07/21/2014] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- M F Dawwas
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Division of Gastroenterology, Department of Medicine, University of California, Irvine, Orange, CA, USA
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Abstract
Methotrexate is effective not only in treating psoriasis and rheumatoid arthritis but also various other disorders. The use of methotrexate has been somewhat limited by concerns regarding its adverse effects, including its potential for hepatotoxicity. The purpose of this article is to provide an overview of methotrexate-associated hepatotoxicity, including risk factors, pathogenesis and recommendations for monitoring it by US, UK and European guidelines, as well as providing a brief overview of its mechanism of action and of high-dose methotrexate.
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Affiliation(s)
- Roopjeet K Bath
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Connecticut Health Center, Farmington, Connecticut, USA
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37
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Zebala JA, Mundell A, Messinger L, Griffin CE, Schuler AD, Kahn SJ. LD-aminopterin in the canine homologue of human atopic dermatitis: a randomized, controlled trial reveals dosing factors affecting optimal therapy. PLoS One 2014; 9:e108303. [PMID: 25255447 PMCID: PMC4177985 DOI: 10.1371/journal.pone.0108303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 08/28/2014] [Indexed: 01/09/2023] Open
Abstract
Background Options are limited for patients with atopic dermatitis (AD) who do not respond to topical treatments. Antifolate therapy with systemic methotrexate improves the disease, but is associated with adverse effects. The investigational antifolate LD-aminopterin may offer improved safety. It is not known how antifolate dose and dosing frequency affect efficacy in AD, but a primary mechanism is thought to involve the antifolate-mediated accumulation of 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR). However, recent in vitro studies indicate that AICAR increases then decreases as a function of antifolate concentration. To address this issue and understand how dosing affects antifolate efficacy in AD, we examined the efficacy and safety of different oral doses and schedules of LD-aminopterin in the canine model of AD. Methods and Findings This was a multi-center, double-blind trial involving 75 subjects with canine AD randomized to receive up to 12 weeks of placebo, once-weekly (0.007, 0.014, 0.021 mg/kg) or twice-weekly (0.007 mg/kg) LD-aminopterin. The primary efficacy outcome was the Global Score (GS), a composite of validated measures of disease severity and itch. GS improved in all once-weekly cohorts, with 0.014 mg/kg being optimal and significant (43%, P<0.01). The majority of improvement was seen by 8 weeks. In contrast, GS in the twice-weekly cohort was similar to placebo and worse than all once-weekly cohorts. Adverse events were similar across all treated cohorts and placebo. Conclusions Once-weekly LD-aminopterin was safe and efficacious in canine AD. Twice-weekly dosing negated efficacy despite having the same daily and weekly dose as effective once-weekly regimens. Optimal dosing in this homologue of human AD correlated with the concentration-selective accumulation of AICAR in vitro, consistent with AICAR mediating LD-aminopterin efficacy in AD.
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Affiliation(s)
- John A. Zebala
- Syntrix Biosystems, Inc., Auburn, Washington, United States of America
- * E-mail:
| | - Alan Mundell
- Animal Dermatology Service, Edmonds, Washington, United States of America
| | - Linda Messinger
- Veterinary Referral Center of Colorado, Englewood, Colorado, United States of America
| | - Craig E. Griffin
- Animal Dermatology Clinic, San Diego, California, United States of America
| | - Aaron D. Schuler
- Syntrix Biosystems, Inc., Auburn, Washington, United States of America
| | - Stuart J. Kahn
- Syntrix Biosystems, Inc., Auburn, Washington, United States of America
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Knudsen CS, Heickendorff L, Nexo E. Measurement of amino terminal propeptide of type III procollagen (PIIINP) employing the ADVIA Centaur platform. Validation, reference interval and comparison to UniQ RIA. Clin Chem Lab Med 2014; 52:237-41. [PMID: 24114914 DOI: 10.1515/cclm-2013-0502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 08/27/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recently, measurement of amino terminal propeptide of type III procollagen (PIIINP) was introduced as a part of the hepatic cirrhotic marker enhanced liver fibrosis™ test on the automated ADVIA Centaur(®) immunoassay platform (Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA). In this article, we show that the Centaur PIIINP may be used in place of the much more labor-intensive RIA method, and we present an age stratified reference interval. METHODS We analyzed four control samples 20 times over a period of 5 days. Centaur PIIINP assay measurements were compared with the widely used UniQ PIIINP RIA assay (Orion Diagnostica, Espoo, Finland) using 55 patient samples (range=3.7-43.3 µg/L). Furthermore, we established a reference interval based on samples from 287 blood donors. RESULTS In the concentration range 2.5-11.9 µg/L, the total imprecision was below 8%. Comparison with the UniQ PIIINP RIA assay yielded: Centaur PIIINP µg/L = 1.9 × (UniQ PIIINP RIA) + 0.6 µg/L, r2=0.94. The reference interval for the Centaur PIIINP assay showed no gender difference but was stratified by age [4.0-11.0 µg/L (18-40 years) and 3.5-9.5 µg/L (41-70 years)]. CONCLUSIONS We conclude that the Centaur PIIINP assay is suitable for routine use with our newly defined reference interval. The results obtained by Centaur correlates well with those obtained by the previously employed RIA, though the absolute values are higher.
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Hardwick RN, Clarke JD, Lake AD, Canet MJ, Anumol T, Street SM, Merrell MD, Goedken MJ, Snyder SA, Cherrington NJ. Increased susceptibility to methotrexate-induced toxicity in nonalcoholic steatohepatitis. Toxicol Sci 2014; 142:45-55. [PMID: 25080921 DOI: 10.1093/toxsci/kfu156] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatic drug metabolizing enzymes and transporters play a crucial role in determining the fate of drugs, and alterations in liver function can place individuals at greater risk for adverse drug reactions (ADRs). We have shown that nonalcoholic steatohepatitis (NASH) leads to changes in the expression and localization of enzymes and transporters responsible for the disposition of numerous drugs. The purpose of this study was to determine the effect of NASH on methotrexate (MTX) disposition and the resulting toxicity profile. Sprague Dawley rats were fed either a control or methionine-choline-deficient diet for 8 weeks to induce NASH, then administered a single ip vehicle, 10, 40, or 100 mg/kg MTX injection followed by blood, urine, and feces collection over 96 h with terminal tissue collection. At the onset of dosing, Abcc1-4, Abcb1, and Abcg2 were elevated in NASH livers, whereas Abcc2 and Abcb1 were not properly localized to the membrane, similar to that previously observed in human NASH. NASH rodents receiving 40-100 mg/kg MTX exhibited hepatocellular damage followed by initiation of repair, whereas damage was absent in controls. NASH rodents receiving 100 mg/kg MTX exhibited slightly greater renal toxicity, indicating multiple organ toxicity, despite the majority of the dose being excreted by 6 h. Intestinal toxicity in NASH however, was strikingly less severe than controls, and coincided with reduced fecal MTX excretion. Because MTX-induced gastrointestinal toxicity limits the dose escalation necessary for cancer remission, these data suggest a greater risk for life-threatening MTX-induced hepatic and renal toxicity in NASH in the absence of overt gastrointestinal toxicity.
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Affiliation(s)
- Rhiannon N Hardwick
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - John D Clarke
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - April D Lake
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - Mark J Canet
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - Tarun Anumol
- Department of Chemical & Environmental Engineering, University of Arizona, Tucson, Arizona 85721
| | - Stephanie M Street
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - Matthew D Merrell
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
| | - Michael J Goedken
- Office of Translational Science, Rutgers University, New Brunswick, New Jersey 08901
| | - Shane A Snyder
- Department of Chemical & Environmental Engineering, University of Arizona, Tucson, Arizona 85721
| | - Nathan J Cherrington
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721
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Martyn-Simmons C, Rosenberg W, Cross R, Wong T, Smith C, Barker J. Validity of noninvasive markers of methotrexate-induced hepatotoxicity: a retrospective cohort study. Br J Dermatol 2014; 171:267-73. [DOI: 10.1111/bjd.12782] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2013] [Indexed: 01/06/2023]
Affiliation(s)
- C.L. Martyn-Simmons
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - W.M.C. Rosenberg
- Division of Medicine; Institute for Liver and Digestive Health; University College London; London U.K
| | - R. Cross
- iQur Ltd; Wolfson Laboratory; Royal Free Hospital; London U.K
| | - T. Wong
- Department of Gastroenterology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - C.H. Smith
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - J.N.W.N. Barker
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
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Carrascosa JM, van Doorn M, Lahfa M, Nestle F, Jullien D, Prinz J. Clinical relevance of immunogenicity of biologics in psoriasis: Implications for treatment strategies. J Eur Acad Dermatol Venereol 2014; 28:1424-30. [DOI: 10.1111/jdv.12549] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 04/10/2014] [Indexed: 11/27/2022]
Affiliation(s)
- J.-M. Carrascosa
- Department of Dermatology; Hospital Universitari Germans Trias i Pujol; Barcelona Spain
| | - M.B.A. van Doorn
- Department of Dermatology; Erasmus MC University Medical Centre; Rotterdam The Netherlands
| | - M. Lahfa
- Department of Dermatology; Hôpital Larrey; Toulouse France
| | - F.O. Nestle
- St. John's Institute of Dermatology; King's College London School of Medicine; London UK
| | - D. Jullien
- Faculty of medicine; University of Lyon; Lyon France
- Department of Dermatology; Hôpital Edouard Herriot; Lyon France
| | - J.C. Prinz
- Clinic for Dermatology and Allergology; Ludwig-Maximilians-University; Munich Germany
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Gyulai R, Bagot M, Griffiths CEM, Luger T, Naldi L, Paul C, Puig L, Kemény L. Current practice of methotrexate use for psoriasis: results of a worldwide survey among dermatologists. J Eur Acad Dermatol Venereol 2014; 29:224-231. [PMID: 24731093 DOI: 10.1111/jdv.12495] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/03/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Methotrexate is one the most commonly used systemic therapies for psoriasis. Despite its widespread use in psoriasis therapy, dermatologists' practice regarding the use of methotrexate has not been investigated on global scale. OBJECTIVE To evaluate the real life use of methotrexate for psoriasis treatment in the dermatological community worldwide. METHODS A questionnaire consisting of 41 questions was designed by the Psoriasis International Network (PIN). Questions focused on safety, dosing, administration, folic acid supplementation and combination therapy aspects of methotrexate use. The anonymous web-based survey was distributed to dermatologists by the national coordinators of PIN. RESULTS Between 2 April and 7 August 2012, 481 dermatologists from 63 countries completed the questionnaire. Most respondents were from European and South American countries, whereas the response rate from Central America and the Near East was lowest. The majority of responders were experienced dermatologists (86% had more than 5 years of experience in psoriasis treatment). Starting and maintenance doses of 10 mg of methotrexate or lower were reported by 67% and 42% of respondents respectively. Thirty-eight per cent of respondents stop treatment at a cumulative dose of 2 g, whereas 36% did not consider cumulative dose important in this respect. The primary mode of administration was oral, and the majority of respondents administer folic acid supplementation. Almost all respondents monitored full blood count, liver and renal function tests, whereas procollagen 3 amino terminal peptide measurement and transient elastography is used by only a minority of dermatologists. There were significant differences concerning the doses, routes of administration and safety monitoring among the clinical practices in different geographical locations. CONCLUSION Current clinical practice of methotrexate use in psoriasis is not uniform, depends on geographical location, and is not in full agreement with clinical guidelines.
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Affiliation(s)
- R Gyulai
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary.,Department of Dermatology, Venereology and Oncodermatology, University of Pécs, Pécs, Hungary
| | - M Bagot
- Department of Dermatology, Saint-Louis Hospital, Paris, France
| | - C E M Griffiths
- Dermatology Centre, Salford Royal Hospital, University of Manchester, Manchester, UK
| | - T Luger
- Department of Dermatology, University of Münster, Münster, Germany
| | - L Naldi
- Department of Dermatology, Azienda Ospedaliera papa Giovanni XXIII, Bergamo, Italy
| | - C Paul
- Department of Dermatology, Paul Sabatier University, CHU Larrey, Toulouse, France
| | - L Puig
- Department of Dermatology, Hospital de la Sanat Creu i Sant Pau, Barcelona, Spain
| | - L Kemény
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
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Abstract
The synthesis rates of fibrillar collagens can be assessed in blood by measuring propeptides set free from corresponding procollagens before fiber formation. Type I collagen is the major component of the organic matrix of bone, but it is also found in other connective tissues. The serum concentration of the amino-terminal propeptide of type I procollagen, PINP, functions as a measure of type I collagen synthesis during normal bone turnover, but it is also released from bone metastases that involve an osteoblastic component. Type III collagen is a major constituent of soft tissues and the corresponding amino-terminal propeptide, PIIINP, reflects collagen synthesis. Circulating PIIINP tends to be affected by malignomas that grow in the peritoneal cavity or affect bone marrow. Many studies on procollagen markers in cancer have been cross-sectional or demonstrated treatment effects in patient groups. Markers that originate from bone turnover have wide reference intervals, but low biologic variability in individuals. Thus, they appear better suited for monitoring versus diagnostic purposes. There is still definite need for research on the use of procollagen markers in the followup of individual patients undergoing cancer treatment or being monitored after such treatment.
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Tomita LY, D'Almeida V, Villa LL, Franco EL, Cardoso MA. Polymorphisms in genes involved in folate metabolism modify the association of dietary and circulating folate and vitamin B-6 with cervical neoplasia. J Nutr 2013; 143:2007-14. [PMID: 24089416 DOI: 10.3945/jn.113.182212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
High folate intake has been suggested as an important factor in cancer prevention; however, previous studies on the relation among folate intake, serum folate, and plasma homocysteine (hcy) are controversial. We conducted a hospital-based, case-control study in Brazil investigating associations between dietary and circulating vitamins B-6 and B-12 and folate, hcy, genotypes of folate-metabolizing enzyme methylenetetrahydrofolate reductase (MTHFR C677T, A1298C), 5-methyltetrahydrofolate-homocysteine methyltransferase (MTR A2756G), methionine synthase reductase (MTRR A66G), and reduced folate carrier (RFC1 G80A) and risk of cervical intraepithelial neoplasia (CIN) grades 1 (CIN1), 2 (CIN2), and 3 (CIN3). The study was composed by 453 controls, 140 CIN1, 126 CIN2, and 231 CIN3. We investigated the joint effects of genetic variants of folate-related genes using genetic risk scores (GRSs) by summing the number of risk alleles for CIN1 and CIN2+ (CIN2 and CIN3 cases). The OR (95% CI) for CIN1 and CIN2+ per each risk allele were 1.29 (1.01, 1.65) and 1.22 (1.01, 1.46), respectively. An association between folate intake and CIN2+ was observed only after stratification according to GRS: crude OR (95% CI) for lower folate intake and GRS ≥ 4 was 1.67 (0.92, 3.04) (P-trend < 0.001) compared with higher folate intake (above the median) and GRS ≤ 3. The CIN2+ risk of lower serum vitamin B-6 and GRS ≥ 4 was 2.14 (0.92, 5.02) (P-trend = 0.05) and lower serum folate (below the median) and GRS ≥ 4 was 0.49 (0.20, 1.17) (P-trend = 0.05) after adjustment for confounding variables and human papillomavirus infection. Our data suggest that polymorphisms in genes related to folate metabolism modify the association of dietary and circulating folate and vitamin B-6 with cervical neoplasia.
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Zargari O, Hejazi S, Shahidi-Dadras M, Younespour S, Robati R, Firooz A, Toosi P, Feldman SR. Considerable variation among Iranian dermatologists in the dosing and monitoring of methotrexate for treating psoriasis. Int J Dermatol 2013; 53:385-9. [PMID: 24134730 DOI: 10.1111/ijd.12201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Methotrexate (MTX) is a risky medication requiring careful attention to dosing and monitoring. Dosing and monitoring practices are not well characterized. AIMS The aim of this study was to assess variation in the dosing and monitoring of methotrexate among Iranian dermatologists. METHODS A questionnaire was administered to forty experts in psoriasis concerning the use of MTX. RESULTS Among the 39 responding dermatologists (15 women, 24 men), 54% saw fewer than 10 psoriatic patients per week, 23% 10-20 patients, and 23% more than 20 patients. About half of the dermatologists treat their patients with an initial MTX dose of <7.5 mg/week (range 5-17.5 mg/week), an average dose of <10 mg/week (range 5-25 mg/week), and a maximum dose of <20 mg/week (range 7.550 – mg/week) with 71.8% prescribing the medication orally and 28.2% intramuscularly. Subcutaneous injection was preferred by none of the dermatologists as a usual route of administration. Nearly 5% of the dermatologists believe that liver biopsy should be performed prior to treatment with MTX in all patients, and another 5% consider this procedure prior to treatment only in patients with risk factors. About 44 and 33% of the dermatologists do the liver biopsy after 1.0-1.5 g and 3.54 g total cumulative doses, respectively. CONCLUSION After more than a half century, there are still noticeable controversies on the manner of using MTX in treating psoriasis among Iranian dermatologists. A national guideline may help standardize treatment practices.
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Affiliation(s)
- Omid Zargari
- Skin Research Center, Shohada Hospital, Tehran, Iran
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van Swelm RP, Laarakkers CM, Kooijmans-Otero M, de Jong EM, Masereeuw R, Russel FG. Biomarkers for methotrexate-induced liver injury: Urinary protein profiling of psoriasis patients. Toxicol Lett 2013; 221:219-24. [DOI: 10.1016/j.toxlet.2013.06.234] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/21/2013] [Accepted: 06/24/2013] [Indexed: 12/18/2022]
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Cutaneous dermatomyositis: an updated review of treatment options and internal associations. Am J Clin Dermatol 2013; 14:291-313. [PMID: 23754636 DOI: 10.1007/s40257-013-0028-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Dermatomyositis is a specific type of inflammatory myopathy with characteristic cutaneous findings. Patients may have skin disease without clinically apparent muscle disease, but this disorder is best thought of as a systemic process. Therefore, all patients with dermatomyositis skin lesions need appropriate evaluation for muscle disease, esophageal dysfunction, cardiopulmonary disease, and potential internal malignancy. There are many therapies that have been used for patients with dermatomyositis, but most are based upon case series or expert opinion rather than meta-analyses or randomized, placebo-controlled trials. Even those therapies that have been subjected to randomized, blinded, placebo-controlled trials include a mixture of patients with idiopathic inflammatory myopathy and do not utilize a validated assessment tool for measuring cutaneous disease responses. In this review, we discuss the therapies available as well as the internal associations with dermatomyositis.
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Yeo CM, Chong VH, Earnest A, Yang WL. Prevalence and risk factors of methotrexate hepatoxicity in Asian patients with psoriasis. World J Hepatol 2013; 5:275-280. [PMID: 23717738 PMCID: PMC3664285 DOI: 10.4254/wjh.v5.i5.275] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish the prevalence of liver fibrosis and to evaluate the possible risk factors for fibrosis and progression in Asian with psoriasis treated with methotrexate (MTX) based on liver histology.
METHODS: Patients with psoriasis treated with MTX referred to the Department of Gastroenterology, Tan Tock Seng Hospital for liver biopsy were identified and retrospectively studied. Patient case notes and electronic records were retrieved from the hospital database and relevant data collated. Histological changes of liver biopsies were staged according to Roengik score. The factors assessed were age, gender, ethnicity, cumulative dose of MTX, presence of comorbid conditions such as diabetes, hypertension, hyperlipidemia, and ethanol use. We also assessed the histological change in those with multiple liver biopsies. Statistical analysis was performed using Stata V.9.2.
RESULTS: There were altogether 59 patients (median age 50 years old, range 22-81 years old, male, 88%) with 98 biopsies liver biopsies; 6 normal [median cumulative dose (MCD), 2285 mg]; 62 grade I (MCD 2885 mg), 23 grade II (MCD 1800 mg) and 7 grade III (MCD 1500 mg). There was no grade IV or cirrhosis. The prevalence of liver fibrosis (grade III) was 12%. Of the factors assessed, diabetes (P = 0.001) and hypertension (P = 0.003) were significant for fibrosis on univariate analysis but not on multivariate analysis. Of the 26 patients who had more than one biopsy (median 2, range 2-6), 57.7% (n = 15) were stable, 34.6% (n = 9) had progression and 7.7% (n = 2) had regression of histological grades. On univariate analysis, non-Chinese ethnicity (P = 0.031), diabetes (P = 0.018), and hyperlipidemia (P = 0.011) were predictive of progression of grades, but these were not significant on multivariate analysis.
CONCLUSION: Liver fibrosis in Asian psoriatic population on MTX is comparable to the West. Cumulative dose was not associated with liver fibrosis. Metabolic syndrome is important factors.
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da Silva CAP, Von Kossel K, Leszczynski M, Melnik T, Riera R. Methotrexate for psoriasis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Carolina AP da Silva
- Universidade Federal de São Paulo; Brazilian Cochrane Centre; Rua Pedro de Toledo, 598 São Paulo São Paulo Brazil 04039-001
| | - Karen Von Kossel
- Universidade Federal de São Paulo; Brazilian Cochrane Centre; Rua Pedro de Toledo, 598 São Paulo São Paulo Brazil 04039-001
| | - Marcos Leszczynski
- Universidade Federal de São Paulo; Brazilian Cochrane Centre; Rua Pedro de Toledo, 598 São Paulo São Paulo Brazil 04039-001
| | - Tamara Melnik
- Universidade Federal de São Paulo; Brazilian Cochrane Centre; Rua Pedro de Toledo, 598 São Paulo São Paulo Brazil 04039-001
| | - Rachel Riera
- Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; R. Borges Lagoa, 564 cj 63 São Paulo São Paulo Brazil 04038000
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Gottlieb AB, Langley RG, Strober BE, Papp KA, Klekotka P, Creamer K, Thompson EHZ, Hooper M, Kricorian G. A randomized, double-blind, placebo-controlled study to evaluate the addition of methotrexate to etanercept in patients with moderate to severe plaque psoriasis. THE BRITISH JOURNAL OF DERMATOLOGY 2013. [PMID: 22533447 DOI: 10.1111/j.1365-2133.2012.11015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Etanercept plus methotrexate combination therapy has not been adequately investigated in psoriasis. OBJECTIVES To evaluate etanercept plus methotrexate vs. etanercept monotherapy in patients with moderate to severe plaque psoriasis who had not failed prior methotrexate or tumour necrosis factor-inhibitor therapy. METHODS Patients received etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks and were randomized 1 : 1 to receive methotrexate (7·5-15 mg weekly) or placebo. The primary endpoint was the proportion of patients achieving ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) at week 24. RESULTS In total, 239 patients were enrolled in each arm. PASI 75 was significantly higher at week 24 for the combination therapy group compared with the monotherapy group (77·3% vs. 60·3%; P < 0·0001). Other PASI improvement scores at week 12 [PASI 75, 70·2% vs. 54·3% (P = 0·01); PASI 50, 92·4% vs. 83·8% (P = 0·01); and PASI 90, 34·0% vs. 23·1% (P = 0·03)] showed similar results as did week 24 PASI 50 (91·6% vs. 84·6%; P = 0·01) and PASI 90 (53·8% vs. 34·2%; P = 0·01). Significantly more patients receiving combination therapy than monotherapy had static Physician's Global Assessment of clear/almost clear at week 12 (65·5% vs. 47·0%; P = 0·01) and week 24 (71·8% vs. 54·3%; P = 0·01). Adverse events (AEs) were reported in 74·9% and 59·8% of combination therapy and monotherapy groups, respectively; three serious AEs were reported in each arm. CONCLUSIONS Combination therapy with etanercept plus methotrexate had acceptable tolerability and increased efficacy compared with etanercept monotherapy in patients with moderate to severe psoriasis.
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