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Ebisawa K, Iwashita T, Uchiyama K, Kitayama Y, Takeuchi T. Epstein-Barr virus-positive mucocutaneous ulcer resulting in severe methotrexate intoxication: a case report. J Med Case Rep 2024; 18:409. [PMID: 39210427 PMCID: PMC11363652 DOI: 10.1186/s13256-024-04730-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Epstein-Barr virus-positive mucocutaneous ulcer is one of the mature B-cell lymphoproliferative diseases occurring in patients with immune dysfunction including those with immunosuppressive treatment such as methotrexate. CASE PRESENTATION A Japanese elderly man in his 80s with rheumatoid arthritis on methotrexate was admitted to our hospital complaining persistent pharyngeal pain. Laboratory tests revealed severe pancytopenia, elevated C-reactive protein, and increased creatinine levels. An otolaryngological examination showed ulceration of the right tonsil, from which diagnostic biopsy was performed. The diagnosis of Epstein-Barr virus-positive mucocutaneous ulcer was made and bone marrow aspiration revealed hypocellularity and megaloblastic changes. Pancytopenia was improved after discontinuing methotrexate, and repeated bone marrow aspiration test revealed recovery of normal cellularity and disappearance of dysplasia, confirming the diagnosis of methotrexate intoxication. Tonsil ulcer was improved only with discontinuation of methotrexate, which strongly supported the diagnosis of EBV-MCU. CONCLUSION Our case suggested that even this best prognosis form of lymphoproliferative disease could lead to fatal complications if not appropriately managed.
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Affiliation(s)
- Kazutoshi Ebisawa
- Department of Hematology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan.
| | - Toshihide Iwashita
- Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kohdai Uchiyama
- Department of Otorhinolaryngology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
| | - Yasuhiko Kitayama
- Department of Pathology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
| | - Takahiro Takeuchi
- Department of Hematology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
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Hosseini E, Shahbazi F. Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature. Curr Drug Saf 2024; 19:224-235. [PMID: 37194235 DOI: 10.2174/1574886318666230516115737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/15/2023] [Accepted: 04/03/2023] [Indexed: 05/18/2023]
Abstract
Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.
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Affiliation(s)
- Elham Hosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Elfarargy RG, Saleh MA, Abodouh MM, Hamza MA, Allam NK. Graphitic Carbon Nitride Nanoheterostructures as Novel Platforms for the Electrochemical Sensing of the Chemotherapeutic and Immunomodulator Agent MTX. BIOSENSORS 2022; 13:51. [PMID: 36671888 PMCID: PMC9856071 DOI: 10.3390/bios13010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
We report on the electrochemical determination of one the most effective and widely used chemotherapeutic, anti-inflammatory, and immunomodulator agents, methotrexate (MTX), using low-cost, green, and facile one-pot prepared graphitic carbon nitride (g-CN ) nanosheets. The g-CN nanosheets have been characterized utilizing Fourier transform infrared spectroscopy, X-ray diffraction(XRD), scanning electron microscopy(SEM), and density functional theory (DFT). In comparison to the bare carbon paste electrode (CPE), the g-CN -modified electrode showed a spectacular enhancement in the electrochemical oxidation and detection abilities of MTX. The proposed material exhibits very low limits of detection (12.45 nM) and quantification (41.5 nM), while possessing a wide linear range of 0.22-1.11 μM and 1.11-27.03 μM under optimized conditions at pH 7.0. Due to the ease of preparation of g-CN, it can be adopted for the cost-effective detection of MTX in industrial and clinical analyses.
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Yadav RK, Gautam DK, Muj C, Gajula Balija MB, Paddibhatla I. Methotrexate negatively acts on inflammatory responses triggered in Drosophila larva with hyperactive JAK/STAT pathway. DEVELOPMENTAL AND COMPARATIVE IMMUNOLOGY 2021; 123:104161. [PMID: 34107277 DOI: 10.1016/j.dci.2021.104161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 06/12/2023]
Abstract
Drosophila is a valuable paradigm for studying tumorigenesis and cancer. Mutations causing hematopoietic aberrations and melanotic-blood-tumors found in Drosophila mutants are vastly studied. Clear understanding about the blood cells, signaling pathways and the tissues affected during hematopoietic tumor formation provide an opportunity to delineate the effects of cancer therapeutics. Using this simple hematopoietic archetype, we elucidated the effects of the anti-cancer drug, Methotrexate (MTX) on immune responses in two scenarios i.e. against wasp infection and in hematopoietic mutant, hopTum-l. Through this in vivo study we show that MTX impedes the immune responses against wasp infection including the encapsulation response. We further observed that MTX reduces the tumor penetrance in gain-of-function mutants of JAK/STAT pathway, hopTum-l. MTX is anti-inflammatory as it hinders not only the immune responses of acute inflammation as observed after wasp infestation, but also chronic inflammatory responses associated with constitutively activated JAK/STAT pathway mutant (hopTum-l) carrying blood tumors.
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Affiliation(s)
- Ravi Kant Yadav
- Department of Biotechnology and Bioinformatics, University of Hyderabad, Hyderabad, 500046, Telangana, India
| | - Dushyant Kumar Gautam
- Department of Biochemistry, University of Hyderabad, Hyderabad, 500046, Telangana, India
| | - Chukhu Muj
- Department of Biotechnology and Bioinformatics, University of Hyderabad, Hyderabad, 500046, Telangana, India
| | - Madhu Babu Gajula Balija
- Department of Biotechnology and Bioinformatics, University of Hyderabad, Hyderabad, 500046, Telangana, India.
| | - Indira Paddibhatla
- Department of Biochemistry, University of Hyderabad, Hyderabad, 500046, Telangana, India.
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5
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Pattanaik S, Jain A, Ahluwalia J. Evolving Role of Pharmacogenetic Biomarkers to Predict Drug-Induced Hematological Disorders. Ther Drug Monit 2021; 43:201-220. [PMID: 33235023 DOI: 10.1097/ftd.0000000000000842] [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: 06/26/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Drug-induced hematological disorders constitute up to 30% of all blood dyscrasias seen in the clinic. Hematologic toxicity from drugs may range from life-threatening marrow aplasia, agranulocytosis, hemolysis, thrombosis to mild leukopenia, and thrombocytopenia. Pathophysiologic mechanisms underlying these disorders vary from an extension of the pharmacological effect of the drug to idiosyncratic and immune-mediated reactions. Predicting these reactions is often difficult, and this makes clinical decision-making challenging. Evidence supporting the role of pharmacogenomics in the management of these disorders in clinical practice is rapidly evolving. Despite the Clinical Pharmacology Implementation Consortium and Pharmacogenomics Knowledge Base recommendations, few tests have been incorporated into routine practice. This review aims to provide a comprehensive summary of the various drugs which are implicated for the hematological adverse events, their underlying mechanisms, and the current evidence and practical recommendations to incorporate pharmacogenomic testing in clinical care for predicting these disorders.
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Affiliation(s)
| | - Arihant Jain
- Internal Medicine, Hematology and Bone Marrow Transplantation, and
| | - Jasmina Ahluwalia
- Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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6
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Tran JQ, Grover D, Zhang M, Stapels M, Brennan R, Bangari DS, Piepenhagen PA, Roberts E, Oliva P, Zubair F, Vela JL, Richards SM, Joseph AM. Expansion of immature, nucleated red blood cells by transient low-dose methotrexate immune tolerance induction in mice. Clin Exp Immunol 2021; 203:409-423. [PMID: 33205401 PMCID: PMC7874831 DOI: 10.1111/cei.13552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
Biological treatments such as enzyme-replacement therapies (ERT) can generate anti-drug antibodies (ADA), which may reduce drug efficacy and impact patient safety and consequently led to research to mitigate ADA responses. Transient low-dose methotrexate (TLD-MTX) as a prophylactic ITI regimen, when administered concurrently with ERT, induces long-lived reduction of ADA to recombinant human alglucosidase alfa (rhGAA) in mice. In current clinical practice, a prophylactic ITI protocol that includes TLD-MTX, rituximab and intravenous immunoglobulin (optional), successfully induced lasting control of ADA to rhGAA in high-risk, cross-reactive immunological material (CRIM)-negative infantile-onset Pompe disease (IOPD) patients. More recently, evaluation of TLD-MTX demonstrated benefit in CRIM-positive IOPD patients. To more clearly understand the mechanism for the effectiveness of TLD-MTX, non-targeted transcriptional and proteomic screens were conducted and revealed up-regulation of erythropoiesis signatures. Confirmatory studies showed transiently larger spleens by weight, increased spleen cellularity and that following an initial reduction of mature red blood cells (RBCs) in the bone marrow and blood, a significant expansion of Ter-119+ CD71+ immature RBCs was observed in spleen and blood of mice. Histology sections revealed increased nucleated cells, including hematopoietic precursors, in the splenic red pulp of these mice. This study demonstrated that TLD-MTX induced a transient reduction of mature RBCs in the blood and immature RBCs in the bone marrow followed by significant enrichment of immature, nucleated RBCs in the spleen and blood during the time of immune tolerance induction, which suggested modulation of erythropoiesis may be associated with the induction of immune tolerance to rhGAA.
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Affiliation(s)
- J. Q. Tran
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
| | - D. Grover
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
| | - M. Zhang
- Sanofi Translational Sciences BioinformaticsCambridgeMAUSA
| | - M. Stapels
- Sanofi Biologics DevelopmentCambridgeMAUSA
| | | | | | | | - E. Roberts
- Sanofi Translational In Vivo ModelsCambridgeMAUSA
| | - P. Oliva
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
| | - F. Zubair
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
| | - J. L. Vela
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
| | - S. M. Richards
- Sanofi Translational Medicine and Early DevelopmentCambridgeMAUSA
| | - A. M. Joseph
- Sanofi Immunology and Inflammation Research Therapeutic AreaCambridgeMAUSA
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AKDAĞ İ, ERSOY A. Development of pancytopenia after single low-dose methotrexate therapy in patients with chronic kidney disease: a review of the literature. TURKISH JOURNAL OF INTERNAL MEDICINE 2020. [DOI: 10.46310/tjim.766086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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8
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Kim JM, Lee WS, Kim J. Therapeutic strategy for atherosclerosis based on bone-vascular axis hypothesis. Pharmacol Ther 2020; 206:107436. [DOI: 10.1016/j.pharmthera.2019.107436] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 12/19/2022]
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Suzuki Y, Sugiyama N, Fukuma Y, Sugiyama N, Kokubo T. RETRACTED ARTICLE: Safety and effectiveness of high-dose methotrexate (over 8 mg/week) in 2838 Japanese patients with rheumatoid arthritis: A postmarketing surveillance report. Mod Rheumatol 2020; 30:vii-xviii. [DOI: 10.1080/14397595.2017.1304857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yasuo Suzuki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Yuri Fukuma
- Medical Affairs, Pfizer Japan Inc., Tokyo, Japan
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Patients with Rheumatoid Arthritis Were Associated with a Risk of Rotator Cuff Diseases. J Clin Med 2019; 8:jcm8020129. [PMID: 30678235 PMCID: PMC6406446 DOI: 10.3390/jcm8020129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 11/17/2022] Open
Abstract
Rheumatoid arthritis (RA) commonly causes inflammation in the joints and periarticular structures. The association between RA and rotator cuff (RC) has been reported; however, epidemiological studies on RA and RC tendons are scant. Therefore, we investigated RC disease (RCD) risk and analyzed the effects of RA medication, steroids, and methotrexate, on the risk of RCD for patients with RA. We conducted a retrospective cohort study with a 6-year longitudinal follow-up in Taiwan. Patients who received RA diagnoses between 2004 and 2008 were enrolled in the study cohort. The non-RA control cohort comprised age- and sex-matched controls. Propensity score matching was used for other comorbidities and treatments. The hazard ratios (HRs) and adjusted HRs (aHRs) were estimated after confounders were adjusted for. Effects of steroid and methotrexate use on RCD risk were also analyzed. We enrolled 4521 RA patients (study cohort) and 22,605 matched controls. RCD incidence was 145 and 91 per 100,000 person-years in the RA and control cohorts, respectively. In the RA cohort, the crude HR for RCD was 1.62 (95% confidence interval (CI), 1.41–1.86, p < 0.001), and the aHR was 1.56 (95% CI, 1.36–1.79, p < 0.001). The methotrexate nonusers exhibited an aHR (vs. controls) of 1.61 (95% CI, 1.40–1.85, p < 0.001), but the methotrexate users did not have a significantly higher aHR than the controls. The steroid nonusers had an aHR (vs. controls) of 1.69 (95% CI, 1.46–1.96, p < 0.001), but the aHR of the steroid users was not significantly higher than the control aHR. Patients with RA had a higher risk for RCD compared with the non-RA control cohort. Steroids or methotrexate use significantly reduces the risk of RCD occurrence in patients with RA. Treatment for RCD symptoms and controlling inflammatory process are important to ensure high-quality care for patients with RA.
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11
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Suzuki Y, Sugiyama N, Fukuma Y, Sugiyama N, Kokubo T. Safety and effectiveness of high-dose methotrexate (over 8 mg/week) in 2838 Japanese patients with rheumatoid arthritis: a postmarketing surveillance report. Mod Rheumatol 2019; 30:24-35. [DOI: 10.1080/14397595.2018.1532483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Yasuo Suzuki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Yuri Fukuma
- Medical Affairs, Pfizer Japan Inc., Tokyo, Japan
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12
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Pereira NRC, Loiola RA, Rodrigues SF, de Oliveira CP, Büttenbender SL, Guterres SS, Pohlmann AR, Farsky SH. Mechanisms of the effectiveness of poly(ε-caprolactone) lipid-core nanocapsules loaded with methotrexate on glioblastoma multiforme treatment. Int J Nanomedicine 2018; 13:4563-4573. [PMID: 30154652 PMCID: PMC6103652 DOI: 10.2147/ijn.s168400] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The low penetration of drugs across the blood-brain barrier (BBB) compromises the delivery of chemotherapeutic agents to the brain parenchyma and contributes to the poor prognosis of glioblastoma multiforme (GBM). We investigated the efficacy of methotrexate-loaded lipid-core nanocapsules (MTX-LNC) administered by the oral route to treat murine GBM, its ability to cross the BBB, and the mechanisms of MTX-LNC uptake by cultured GL261 glioma and BV2 microglia cells. MATERIALS AND METHODS Female C57B/6 mice were used in intravital microscopy assays to investigate the penetrance of rhodamine B-label MTX-LNC (RhoB/MTX-LNC) in the brain after oral or IV administration, and to evaluate the BBB integrity. Intracranial implantation of GL261 cells was undertaken to induce a murine GBM model, and the effectiveness of oral MTX or MTX-LNC treatments (started on Day 10 of GBM, every 2 days for 12 days) was quantified by tumor size, body weight, and leukogram. Pharmacological blockade of endocytic pathways was done to investigate the mechanisms of MTX-LNC uptake by cultured GL261 and microglia BV2 cells by using fluorescence microscopy. The effect of MTX-LNC or MTX on GL261 and BV2 proliferation was evaluated to compare the cytotoxicity of such compounds. RESULTS RhoB/MTX-LNC was detected in brain parenchyma of mice after IV or oral administration, without any damage on BBB. Oral treatment with MTX-LNC reduced tumor volume and prevented weight loss and leukopenia in comparison to MTX-treated mice. MTX-LNC uptake by GL261 is caveolae-dependent, whereas endocytosis of MTX-LNC by BV2 occurs via phagocytosis and macropinocytosis. Both MTX-LNC and MTX reduced GL261 and BV2 proliferation; however, MTX-LNC showed higher efficacy in the inhibition of glioma proliferation. CONCLUSION Together, we infer that the higher ability of MTX-LNC to cross the BBB and be captured by cancer and immune brain cells by different mechanisms is responsible for the higher efficacy of oral MTX-LNC treatment in GBM.
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Affiliation(s)
- Natalia Rubio Claret Pereira
- Department of Clinical and Toxicological Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, Sao Paulo, Brazil,
| | - Rodrigo Azevedo Loiola
- Department of Clinical and Toxicological Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, Sao Paulo, Brazil,
| | - Stephen Fernandes Rodrigues
- Department of Clinical and Toxicological Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, Sao Paulo, Brazil,
| | | | - Sabrina L Büttenbender
- Department of Organic Chemistry, Institute of Chemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Silvia S Guterres
- Faculty of Pharmacy, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Adriana R Pohlmann
- Department of Organic Chemistry, Institute of Chemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sandra H Farsky
- Department of Clinical and Toxicological Analysis, Faculty of Pharmaceutical Sciences, University of São Paulo, Sao Paulo, Brazil,
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Manappallil RG, Prasan D, Peringat J, Biju IK. Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury. BMJ Case Rep 2018; 2018:bcr-2018-224722. [PMID: 29871962 PMCID: PMC5990089 DOI: 10.1136/bcr-2018-224722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 12/17/2022] Open
Abstract
Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.
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Affiliation(s)
| | - Durga Prasan
- Medical Oncology, Baby Memorial Hospital, Calicut, Kerala, India
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Mathai PC, Andrade NN, Aggarwal N, Nerurkar S, Kapoor P. Low-dose methotrexate in rheumatoid arthritis: a potential risk factor for bisphosphonate-induced osteonecrosis of the jaw. Oral Maxillofac Surg 2018; 22:235-240. [PMID: 29508096 DOI: 10.1007/s10006-018-0688-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
Bisphosphonate-induced osteonecrosis of the jaw [BIONJ] is a relatively new pathological condition which was first described in the year 2003. The prevalence of BIONJ in patients on oral formulations is around 0.05% within the first 3 years and increases up to 0.2% after 4 years of consumption. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases [e.g., high doses of methotrexate up to 30 mg daily] significantly increase the chances of acquiring BIONJ. We present three patients with osteoporosis and rheumatoid arthritis [RA] who consumed oral bisphosphonates [alendronate] for less than 1 year and developed BIONJ within 2 to 5 months of undergoing a traumatic dental procedure. The patients also gave a history of consuming low doses of methotrexate [disease-modifying anti-rheumatic drugs] up to 20 mg weekly for 4 to 10 years. No history of steroid consumption was given by any of the patients. This case series highlights the possibility of rheumatoid arthritis and low-dose methotrexate being potential risk factors for BIONJ. This may be on account of the synergistic effect of methotrexate and bisphosphonates and the pro-inflammatory state created by RA which increased the risk of acquiring BIONJ.
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Affiliation(s)
- Paul C Mathai
- Department of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai, 400008, India
| | - Neelam N Andrade
- Department of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai, 400008, India.
| | - Neha Aggarwal
- Department of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai, 400008, India
| | - Shibani Nerurkar
- Department of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai, 400008, India
| | - Prathmesh Kapoor
- Department of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai, 400008, India
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Shao SC, Yang YHK, Chien PS, Lai ECC. Methotrexate-induced pancytopenia in a patient with ectopic pregnancy. Arch Med Sci 2018; 14:475-476. [PMID: 29593825 PMCID: PMC5868656 DOI: 10.5114/aoms.2016.58844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- Shih-Chieh Shao
- Department of Pharmacy, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Shien Chien
- Department of Obstetrics and Gynecology, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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16
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Kwon OC, Lee JS, Kim YG, Lee CK, Yoo B, Hong S. Safety of the concomitant use of methotrexate and a prophylactic dose of trimethoprim-sulfamethoxazole. Clin Rheumatol 2018; 37:3215-3220. [DOI: 10.1007/s10067-018-4005-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 01/18/2018] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
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17
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Tam HW, Chen CM, Leong PY, Chen CH, Li YC, Wang YH, Lin LC, Chiou JY, Wei JCC. Methotrexate might reduce ischemic stroke in patients with rheumatoid arthritis: a population-based retrospective cohort study. Int J Rheum Dis 2018; 21:1591-1599. [PMID: 29372595 DOI: 10.1111/1756-185x.13267] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To investigate the effects of hydroxychloroquine, sulfasalazine and methotrexate on ischemic stroke in patients with rheumatoid arthritis (RA). METHODS This population-based retrospective cohort study included 7904 RA patients and 15 808 non-RA patients between 2000 and 2010. All of the participants were sampled from the National Health Insurance Research Database (NHIRD) of Taiwan. Using univariate analyses, these two groups of patients were compared to evaluate the differences in disease-modifying anti-rheumatic drugs usage and demographic variables. Cox proportional hazard models and Schoenfeld residuals test were performed to estimate the hazard ratios for ischemic stroke and proportional hazard assumptions of these drugs, respectively. RESULTS The mean age of participants was about 53 years old, and about 70% of RA patients were women. The hazard ratio for ischemic stroke was 1.21 (95% CI: 1.10-1.34; P < 0.01) in the case group compared with the control group, and this significant difference persisted throughout the 10-year period. With respect to RA patients, while hydroxychloroquine showed an insignificant protective effect on ischemic stroke, sulfasalazine and methotrexate were found out to have inconsistent effects during these 10 years. The proportional hazard assumption test of methotrexate at > 0.5 defined daily dose (8.75 mg/week) was violated at a significant level after adjustment (P = 0.0002). CONCLUSIONS At a dosage of > 0.5 defined daily dose, short-term methotrexate might decrease ischemic stroke risk in RA patients, while hydroxychloroquine and sulfasalazine were neutral.
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Affiliation(s)
- Hong-Wei Tam
- School of Medicine, Chung Shan Medical University, Tai Chung, Taiwan
| | - Chyong-Mei Chen
- Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Pui-Ying Leong
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Tai Chung, Taiwan.,Institute of Medicine, Chung Shan Medical University Hospital, Tai Chung, Taiwan
| | - Chao-Hsi Chen
- School of Medicine, Chung Shan Medical University, Tai Chung, Taiwan
| | - Yuan-Chao Li
- School of Medicine, Chung Shan Medical University, Tai Chung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Tai Chung, Taiwan
| | - Li-Chi Lin
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Tai Chung, Taiwan.,Institute of Medicine, Chung Shan Medical University Hospital, Tai Chung, Taiwan.,Department of Statistics, Oklahoma State University, Stillwater, OK, USA
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Tai Chung, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Tai Chung, Taiwan.,Institute of Medicine, Chung Shan Medical University Hospital, Tai Chung, Taiwan.,Institute of Integrative Medicine, China Medical University, Tai Chung, Taiwan
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18
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Iqbal F, Baker WS, Khan MI, Thukuntla S, McKinney KH, Abate N, Tuvdendorj D. Current and future therapies for addressing the effects of inflammation on HDL cholesterol metabolism. Br J Pharmacol 2017; 174:3986-4006. [PMID: 28326542 PMCID: PMC5660004 DOI: 10.1111/bph.13743] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/16/2017] [Accepted: 02/02/2017] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. Inflammatory processes arising from metabolic abnormalities are known to precipitate the development of CVD. Several metabolic and inflammatory markers have been proposed for predicting the progression of CVD, including high density lipoprotein cholesterol (HDL-C). For ~50 years, HDL-C has been considered as the atheroprotective 'good' cholesterol because of its strong inverse association with the progression of CVD. Thus, interventions to increase the concentration of HDL-C have been successfully tested in animals; however, clinical trials were unable to confirm the cardiovascular benefits of pharmaceutical interventions aimed at increasing HDL-C levels. Based on these data, the significance of HDL-C in the prevention of CVD has been called into question. Fundamental in vitro and animal studies suggest that HDL-C functionality, rather than HDL-C concentration, is important for the CVD-preventive qualities of HDL-C. Our current review of the literature positively demonstrates the negative impact of systemic and tissue (i.e. adipose tissue) inflammation in the healthy metabolism and function of HDL-C. Our survey indicates that HDL-C may be a good marker of adipose tissue health, independently of its atheroprotective associations. We summarize the current findings on the use of anti-inflammatory drugs to either prevent HDL-C clearance or improve the function and production of HDL-C particles. It is evident that the therapeutic agents currently available may not provide the optimal strategy for altering HDL-C metabolism and function, and thus, further research is required to supplement this mechanistic approach for preventing the progression of CVD. LINKED ARTICLES This article is part of a themed section on Targeting Inflammation to Reduce Cardiovascular Disease Risk. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.22/issuetoc and http://onlinelibrary.wiley.com/doi/10.1111/bcp.v82.4/issuetoc.
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Affiliation(s)
- Fatima Iqbal
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Wendy S Baker
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Madiha I Khan
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Shwetha Thukuntla
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Kevin H McKinney
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Nicola Abate
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Demidmaa Tuvdendorj
- Division of Endocrinology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
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19
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Abstract
The majority of rheumatic diseases are chronic and require long-term use of disease-modifying agents to confer the best chance of controlling the disease. A significant proportion of these drugs have a risk, albeit small, of potentially serious side effects, such as neutropenia; therefore, there has been an understandable concern over the use of potentially toxic rheumatic drugs in the elderly. Factors that may contribute to this concern include age, pre-existing co-morbidities, polypharmacy, difficulty in monitoring side effects, and patient perception. The risk of using such medication needs to be balanced with their benefits in controlling chronic disease. This review discusses how rheumatic disease and anti-rheumatic medication are associated with neutropenia in an older age group. Of the rheumatic diseases, we give special focus to rheumatoid arthritis and the use of methotrexate, as well as touching on management considerations in neutropenia.
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20
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Mortensen KL, Krogh TP, Jensen-Fangel S, Hauge EM. Severe acute pancytopaenia in a patient with rheumatoid arthritis complicated by fatal invasive pulmonary aspergillosis. Scand J Rheumatol 2016; 46:249-250. [PMID: 27575284 DOI: 10.1080/03009742.2016.1209553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- K L Mortensen
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark.,b Department of Medicine , Randers Regional Hospital , Randers , Denmark
| | - T P Krogh
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - S Jensen-Fangel
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark
| | - E M Hauge
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark.,d Department of Clinical Medicine , Aarhus University , Aarhus , Denmark
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21
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Muhvić-Urek M, Tomac-Stojmenović M, Mijandrušić-Sinčić B. Oral pathology in inflammatory bowel disease. World J Gastroenterol 2016; 22:5655-5667. [PMID: 27433081 PMCID: PMC4932203 DOI: 10.3748/wjg.v22.i25.5655] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/27/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
The incidence of inflammatory bowel diseases (IBD) - Crohn’s disease (CD) and ulcerative colitis (UC) - has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.
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22
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Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) are chronic inflammatory disorders, which require long term treatment to achieve remission and to prevent relapses and cancer. While current therapies are effective in most cases, they can have rare but serious side effects and are often associated with high costs. On the other hand, early discontinuation of an effective treatment may lead to a quick relapse and to complications at the restart of therapy. Therefore it is essential to determine the optimal duration of maintenance therapy, but clear guidelines are missing. The most important questions when deciding whether to continue or withdraw therapy in quiescent UC and CD patients are the efficacy of the continuous treatment to maintain remission in the long term, the frequency and severity of side effects, and the chance of relapse after discontinuation of therapy. This review summarizes the current knowledge on these topics with respect to 5-aminosalicylates, thiopurines, methotrexate, and biological therapies and collects information regarding when and in which specific patient groups, in the absence of risk factors, can withdrawal of therapy be considered without a high risk of relapse. Additionally, the particular aspect of colorectal cancer prevention by current therapies will also be discussed.
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23
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Oral mucositis in patients receiving low-dose methotrexate therapy for rheumatoid arthritis: report of 2 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:e28-33. [PMID: 23601229 DOI: 10.1016/j.oooo.2012.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 12/02/2012] [Accepted: 12/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The differential diagnosis of ulcerative oral lesions is diverse. This report discusses the rare causes of oral mucosal ulceration and suggests approaches for diagnosis and treatment. METHODS Two cases of methotrexate-induced stomatitis in patients receiving low dose methotrexate for rheumatoid arthritis are presented with a review of the current literature. In case 1, mucositis was caused by an unintended methotrexate overdose. In case 2, oral lesions were the result of chronic methotrexate toxicity. The treatment for methotrexate-induced mucositis required hospitalization in case 1, methotrexate discontinuation in both cases and oral folic acid supplementation in case 2. RESULTS In both cases, the mucositis healed and no relapse was observed. CONCLUSION Mucositis may be an early sign of systemic conditions, and dental providers are often the first doctors involved in the assessment of oral mucosal diseases. Meticulous questioning of the patient's history and the physical examination is important for elucidating the underlying cause.
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24
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Fan C, Georgiou KR, King TJ, Xian CJ. Methotrexate toxicity in growing long bones of young rats: a model for studying cancer chemotherapy-induced bone growth defects in children. J Biomed Biotechnol 2011; 2011:903097. [PMID: 21541196 PMCID: PMC3085506 DOI: 10.1155/2011/903097] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 01/21/2011] [Indexed: 11/17/2022] Open
Abstract
The advancement and intensive use of chemotherapy in treating childhood cancers has led to a growing population of young cancer survivors who face increased bone health risks. However, the underlying mechanisms for chemotherapy-induced skeletal defects remain largely unclear. Methotrexate (MTX), the most commonly used antimetabolite in paediatric cancer treatment, is known to cause bone growth defects in children undergoing chemotherapy. Animal studies not only have confirmed the clinical observations but also have increased our understanding of the mechanisms underlying chemotherapy-induced skeletal damage. These models revealed that high-dose MTX can cause growth plate dysfunction, damage osteoprogenitor cells, suppress bone formation, and increase bone resorption and marrow adipogenesis, resulting in overall bone loss. While recent rat studies have shown that antidote folinic acid can reduce MTX damage in the growth plate and bone, future studies should investigate potential adjuvant treatments to reduce chemotherapy-induced skeletal toxicities.
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Affiliation(s)
- Chiaming Fan
- Sansom Institute for Health Research, and School of Pharmacy and Medical Sciences, University of South Australia, City East Campus, GPO Box 2471, Adelaide, SA 5001, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, SA 5005, Australia
| | - Kristen R. Georgiou
- Sansom Institute for Health Research, and School of Pharmacy and Medical Sciences, University of South Australia, City East Campus, GPO Box 2471, Adelaide, SA 5001, Australia
- Discipline of Physiology, University of Adelaide, Adelaide, SA 5005, Australia
| | - Tristan J. King
- Sansom Institute for Health Research, and School of Pharmacy and Medical Sciences, University of South Australia, City East Campus, GPO Box 2471, Adelaide, SA 5001, Australia
- Discipline of Physiology, University of Adelaide, Adelaide, SA 5005, Australia
| | - Cory J. Xian
- Sansom Institute for Health Research, and School of Pharmacy and Medical Sciences, University of South Australia, City East Campus, GPO Box 2471, Adelaide, SA 5001, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, SA 5005, Australia
- Discipline of Physiology, University of Adelaide, Adelaide, SA 5005, Australia
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25
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Katchamart W, Bourré-Tessier J, Donka T, Drouin J, Rohekar G, Bykerk VP, Haraoui B, Leclerq S, Mosher DP, Pope JE, Shojania K, Thomson J, Thorne JC, Bombardier C. Canadian recommendations for use of methotrexate in patients with rheumatoid arthritis. J Rheumatol 2010; 37:1422-30. [PMID: 20516029 DOI: 10.3899/jrheum.090978] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To develop recommendations for the use of methotrexate (MTX) in patients with rheumatoid arthritis. METHODS Canadian rheumatologists who participated in the international 3e Initiative in Rheumatology (evidence, expertise, exchange) in 2007-2008 formulated 5 unique Canadian questions. A bibliographic team systematically reviewed the relevant literature on these 5 topics. An expert committee consisting of 26 rheumatologists from across Canada was convened, and a set of recommendations was proposed based on the results of systematic reviews combined with expert opinions using a nominal group consensus process. RESULTS The 5 questions addressed drug interactions, predictors of response, strategies to reduce non-serious side effects, variables to assess clinical response, and incorporating patient preference into decision-making. The systematic review retrieved 93 pertinent articles; this evidence was presented to the expert committee during the interactive workshop. After extensive discussion and voting, a total of 9 recommendations were formulated: 2 on drug interactions, 1 on predictors of response, 2 on strategies to reduce non-serious side effects, 3 on variables to assess clinical response, and 1 on incorporating patient preferences into decision-making. The level of evidence and the strength of recommendations are reported. Agreement among panelists ranged from 85% to 100%. CONCLUSION Nine recommendations pertaining to the use of MTX in daily practice were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement.
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26
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Lucas J, Ntuen E, Pearce DJ, Fleischer AB, Feldman SR. Methotrexate: understanding the risk in psoriasis patients. J DERMATOL TREAT 2010; 20:311-3. [PMID: 19363738 DOI: 10.1080/09546630902877931] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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27
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Bourré-Tessier J, Haraoui B. Methotrexate drug interactions in the treatment of rheumatoid arthritis: a systematic review. J Rheumatol 2010; 37:1416-21. [PMID: 20436072 DOI: 10.3899/jrheum.090153] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) often have comorbidities that require multiple medications. Several of these medications may alter the efficacy or increase the toxicity of methotrexate (MTX). The purpose of our study was to determine which drugs used in combination with MTX (excluding disease modifying antirheumatic drugs, folic and folinic acid, corticosteroids, and biologic agents) enhance side effects or toxicity of MTX or lower its efficacy. METHODS A systematic literature search was performed with Medline, Embase, Cochrane Register and Database, and abstracts from the 2006/2007 annual congresses of the American College of Rheumatology and the European League Against Rheumatism. A manual search of the citation lists of retrieved publications was performed. RESULTS Of the 1172 articles identified, 67 were included: 21 pharmacokinetics studies, 5 observational studies, and 78 case reports. Most medications do not significantly affect the pharmacokinetics profile of MTX. Among the clinical studies, cytopenia and elevation of liver enzymes were the main reported toxicities. The use of trimethoprim-sulfamethoxazole (TMP-SMX) was mentioned as a risk factor for developing cytopenia in one observational study and in 17 case reports. Thirty case reports of cytopenia were attributed to the use of concomitant nonsteroidal antiinflammatory drugs, including acetylsalicylic acid. Two studies described mild abnormalities of liver enzymes with the use of isoniazid, and one study with the use of high-dose ASA. CONCLUSION Based on the published literature, MTX has limited drug interactions, with the exception of TMP-SMX and high-dose ASA, which can exacerbate toxicity of MTX. The clinical significance of these interactions has not been substantiated by extensive clinical observations.
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Affiliation(s)
- Josiane Bourré-Tessier
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Université de Montréal,Montréal, Québec, Canada.
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Kuitunen T, Malmström J, Palva E, Pettersson T. Pancytopenia induced by low‐dose methotrexate. A study of the cases reported to the Finnish Adverse Drug Reaction Register from 1991 to 1999. Scand J Rheumatol 2009; 34:238-41. [PMID: 16134732 DOI: 10.1080/03009740510018570] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study cases of low-dose methotrexate-induced pancytopenia with special reference to clinical outcome and factors predisposing to bone marrow suppression. METHODS Patient files of 14 cases of methotrexate-induced pancytopenia reported to the National Agency for Medicines in Finland from 1991 to 1999 were reviewed. A review of four additional cases was included. RESULTS Of the 18 patients (median age 72 years), 12 had rheumatoid arthritis, one psoriatic arthritis, five psoriasis without arthritis, and one pemphigus erythematosus. Major co-morbidity was recorded in 12 patients, and 16 patients used significant concomitant drugs. Eight patients had a mildly or moderately elevated serum creatinine concentration. In every patient the occurrence of cytopenia was abrupt. Eight patients (44%) died, and the most frequent cause of death was infection. CONCLUSIONS Our data show that methotrexate-induced pancytopenia is associated with high mortality especially in cases with significant co-morbidity and concomitant medications.
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Affiliation(s)
- T Kuitunen
- Department of Medicine, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland.
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29
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Fan C, Cool JC, Scherer MA, Foster BK, Shandala T, Tapp H, Xian CJ. Damaging effects of chronic low-dose methotrexate usage on primary bone formation in young rats and potential protective effects of folinic acid supplementary treatment. Bone 2009; 44:61-70. [PMID: 18976724 DOI: 10.1016/j.bone.2008.09.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 09/24/2008] [Accepted: 09/25/2008] [Indexed: 10/21/2022]
Abstract
Methotrexate (MTX) is a most commonly used anti-metabolite in cancer treatment and as an anti-rheumatic drug. While MTX chemotherapy at a high dose is known to cause bone growth defects in growing bones, effects of its chronic use at a low dose on growing skeleton remain less clear. Here, we examined effects on bone growth of long-term MTX chemotherapy at a low dose in young rats, and potential protective effects of supplementary treatment with antidote folinic acid (given ip at 1 mg/kg 6 h after MTX). After two cycles of 5 once-daily MTX injections (at 0.75 mg/kg, 5 days on/9 days off/5 days on), histological analysis showed that MTX at this dose caused significant reduction in heights of growth plate and primary spongiosa bone on day 22 compared to controls (P<0.05). In contrast, a similar dosing regimen but at a lower dose (0.4 mg/kg) caused only slight or no reduction in heights of both regions. However, after the induction phase at this 0.4 mg/kg dosing, continued use of MTX at a low dose (once weekly at 0.2 mg/kg) caused a reduction in primary spongiosa height and bone volume on weeks 9 and 14, which was associated with an increased osteoclast formation and their bone surface density as well as a decreased osteoblast bone surface density in the primary spongiosa. Folinic acid supplementation was shown able to prevent the MTX effects in the primary spongiosa. These results suggest that acute use of MTX can damage growth plate and primary bone at a high dose, but not at a low dose. However, long-term use of MTX at a low dose can reduce primary bone formation probably due to decreased osteoblastic function but increased osteoclastic formation and function, and supplementary treatment with folinic acid may be potentially useful in protecting bone growth during long-term low-dose MTX chemotherapy.
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Affiliation(s)
- Chiaming Fan
- Department of Orthopaedic Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
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Bookstaver PB, Norris L, Rudisill C, DeWitt T, Aziz S, Fant J. Multiple toxic effects of low-dose methotrexate in a patient treated for psoriasis. Am J Health Syst Pharm 2008; 65:2117-21. [DOI: 10.2146/ajhp070676] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - LeAnn Norris
- South Carolina College of Pharmacy, University of South Carolina, Columbia
| | - Celeste Rudisill
- South Carolina College of Pharmacy, University of South Carolina, Columbia
| | - Tammy DeWitt
- University of Virginia Health System, Charlottesville. At the time of writing, she was Post Graduate Year One Resident, Palmetto Health Richland, Columbia
| | | | - James Fant
- Division of Rheumatology, School of Medicine, University of South Carolina
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Oral versus parenteral administration of methotrexate for the treatment of active RA. ACTA ACUST UNITED AC 2008; 4:342-3. [DOI: 10.1038/ncprheum0827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 04/11/2008] [Indexed: 11/08/2022]
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Smellie WSA, Shaw N, Bowley R, Stewart MF, Kelly AM, Twomey PJ, Chadwick PR, Houghton JB, Ng JP, McCulloch AJ. Best practice in primary care pathology: review 10. J Clin Pathol 2007; 60:1195-204. [PMID: 17496187 PMCID: PMC2095485 DOI: 10.1136/jcp.2007.048512] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2007] [Indexed: 01/03/2023]
Abstract
This tenth best practice review examines four series of common primary care questions in laboratory medicine: (i) antenatal testing in pregnant women; (ii) estimated glomerular filtration rate calculation; (iii) safety testing for methotrexate; and (iv) blood glucose measurement in diabetes. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.
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Affiliation(s)
- W S A Smellie
- Department of Chemical Pathology, Bishop Auckland General Hospital, Bishop Auckland, UK.
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Stamp L, Roberts R, Kennedy M, Barclay M, O'Donnell J, Chapman P. The use of low dose methotrexate in rheumatoid arthritis - are we entering a new era of therapeutic drug monitoring and pharmacogenomics? Biomed Pharmacother 2006; 60:678-87. [PMID: 17071051 DOI: 10.1016/j.biopha.2006.09.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Accepted: 09/22/2006] [Indexed: 02/08/2023] Open
Abstract
Methotrexate (MTX) is one of the most commonly used medications in the treatment of rheumatoid arthritis (RA). It has proven efficacy as a sole agent as well as in combination with other disease modifying anti-rheumatic agents (DMARDs) including the newer biological agents. MTX is generally well tolerated although there are a number of potentially serious adverse effects. Of these, haematopoietic suppression, hepatotoxicity and pulmonary toxicity are the more severe and patients are therefore required to have appropriate monitoring while they remain on MTX. In the past, attempts at therapeutic drug monitoring using serum MTX concentrations have been unsuccessful. However, MTX is taken into red blood cells (RBC) where up to four glutamates are added to form MTX polyglutamates (MTXPG(n)). More recently it has been suggested that higher RBC MTXPG(3-5) concentrations may be associated with improved disease control. Genetic variations in enzymes involved in the uptake of MTX into cells and its metabolism are also being examined for their ability to predict drug response and potential for adverse events. While it is unlikely that a single genetic variant will predict efficacy or toxicity there is preliminary evidence that a "pharmacogenetic index" that takes into account the effects of multiple genetic variants maybe useful. Although in their infancy at present, both therapeutic drug monitoring using MTXPG concentrations and pharmacogenomics of MTX may prove useful in the future and are worthy of further investigation.
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Affiliation(s)
- Lisa Stamp
- Department of Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, P. O. Box 4345, Christchurch, New Zealand.
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Preet Singh Y, Aggarwal A, Misra R, Agarwal V. Low-dose methotrexate-induced pancytopenia. Clin Rheumatol 2006; 26:84-7. [PMID: 16636937 DOI: 10.1007/s10067-006-0301-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Revised: 04/02/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
Methotrexate (MTX) has gained wide acceptance among both patients and rheumatologists due to its efficacy and safe therapeutic window in a variety of inflammatory rheumatological disorders. However, it has the potential to cause serious, life-threatening complications and even mortality. In the present series, we have reviewed our data of five patients who developed serious pancytopenia after the use of MTX, including one who died. Two of these resulted from prescription errors by primary care physicians. The clinical, laboratory, and outcome profile of all five cases are discussed with a brief review of the literature about MTX-induced pancytopenia. There is an urgent need to increase awareness in primary care physicians, patients, and pharmacists toward informed prescribing, dispensing, and monitoring of MTX to prevent such mishaps in the future.
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Affiliation(s)
- Yogesh Preet Singh
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Deeming GMJ, Collingwood J, Pemberton MN. Methotrexate and oral ulceration. Br Dent J 2005; 198:83-5. [PMID: 15702101 DOI: 10.1038/sj.bdj.4811972] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2003] [Accepted: 01/19/2004] [Indexed: 12/28/2022]
Abstract
Methotrexate is well established in the drug treatment of various neoplastic diseases. More recently it has become increasingly used as a once-weekly, low-dose treatment of disorders such as psoriasis and rheumatoid arthritis. Clinical trials have shown its effectiveness in these conditions and it is likely that dentists will encounter patients taking this drug in general dental practice. Oral ulceration can occur as a side effect of methotrexate therapy. This may be due to lack of folic acid supplementation or overdosage due to confusion regarding its once-weekly regime. Illustrations of these problems, which have initially presented in a dental setting, are given. Important drug interactions of methotrexate relevant to dentistry are discussed.
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Affiliation(s)
- G M J Deeming
- Unit of Oral Medicine, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH
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Clarke AK. Methotrexate and bone marrow suppression: standard collaborative care will be made more difficult. BMJ 2003; 326:1145; author reply 1145-6. [PMID: 12764000 PMCID: PMC514060 DOI: 10.1136/bmj.326.7399.1145-c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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