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Coskun BN, Yagiz B, Ocakoglu G, Dalkilic E, Pehlivan Y. Assessing the accuracy and completeness of artificial intelligence language models in providing information on methotrexate use. Rheumatol Int 2024; 44:509-515. [PMID: 37747564 DOI: 10.1007/s00296-023-05473-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023]
Abstract
We aimed to assess Large Language Models (LLMs)-ChatGPT 3.5-4, BARD, and Bing-in their accuracy and completeness when answering Methotrexate (MTX) related questions for treating rheumatoid arthritis. We employed 23 questions from an earlier study related to MTX concerns. These questions were entered into the LLMs, and the responses generated by each model were evaluated by two reviewers using Likert scales to assess accuracy and completeness. The GPT models achieved a 100% correct answer rate, while BARD and Bing scored 73.91%. In terms of accuracy of the outputs (completely correct responses), GPT-4 achieved a score of 100%, GPT 3.5 secured 86.96%, and BARD and Bing each scored 60.87%. BARD produced 17.39% incorrect responses and 8.7% non-responses, while Bing recorded 13.04% incorrect and 13.04% non-responses. The ChatGPT models produced significantly more accurate responses than Bing for the "mechanism of action" category, and GPT-4 model showed significantly higher accuracy than BARD in the "side effects" category. There were no statistically significant differences among the models for the "lifestyle" category. GPT-4 achieved a comprehensive output of 100%, followed by GPT-3.5 at 86.96%, BARD at 60.86%, and Bing at 0%. In the "mechanism of action" category, both ChatGPT models and BARD produced significantly more comprehensive outputs than Bing. For the "side effects" and "lifestyle" categories, the ChatGPT models showed significantly higher completeness than Bing. The GPT models, particularly GPT 4, demonstrated superior performance in providing accurate and comprehensive patient information about MTX use. However, the study also identified inaccuracies and shortcomings in the generated responses.
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Affiliation(s)
- Belkis Nihan Coskun
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey.
| | - Burcu Yagiz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Gokhan Ocakoglu
- Department of Biostatistics, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Ediz Dalkilic
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Yavuz Pehlivan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
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2
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Fiehn C, Leipe J, Weseloh C, Bergner R, Krüger K. Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search. Z Rheumatol 2024; 83:8-19. [PMID: 37831190 DOI: 10.1007/s00393-023-01417-3] [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] [Accepted: 08/14/2023] [Indexed: 10/14/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective product information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
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Affiliation(s)
- C Fiehn
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany.
- Tätigkeitsschwerpunkt klinische Immunologie, Rheumatologie Baden-Baden, Beethovenstr. 2, 76530, Baden-Baden, Germany.
| | - J Leipe
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- V. Medizinische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany
| | - C Weseloh
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
| | - R Bergner
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Medizinische Klinik A, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - K Krüger
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Rheumatologisches Praxiszentrum St. Bonifatius, Munich, Germany
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3
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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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4
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Xiong A, Luo W, Tang X, Cao Y, Xiang Q, Deng R, Shuai S. Risk factors for invasive fungal infections in patients with connective tissue disease: Systematic review and meta-analysis. Semin Arthritis Rheum 2023; 63:152257. [PMID: 37633041 DOI: 10.1016/j.semarthrit.2023.152257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE Invasive fungal infections (IFIs) are life-threatening opportunistic infections in patients with connective tissue disease CTD) that cause significant morbidity and mortality. We attempted to determine the potential risk factors associated with IFIs in CTD. METHODS We systematically searched PubMed, Embase, and the Cochrane Library databases for relevant articles published from the database inception to February 1, 2023. RESULTS Twenty-six studies were included in this systematic review and meta-analysis. Risk factors identified for IFIs were diabetes (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.00 to 2.64), pulmonary diseases (OR 3.43; 95% CI 2.49 to 4.73), interstitial lung disease (ILD; OR, 4.06; 95% CI, 2.22 to 7.41), renal disease (OR, 4.41; 95% CI, 1.84 to 10.59), glucocorticoid (GC) use (OR, 4.15; 95% CI, 2.74 to 6.28), especially moderate to high-dose GC, azathioprine (AZA) use (OR, 1.50; 95% CI, 1.12 to 2.01), calcineurin inhibitor (CNI) use (OR, 2.49; 95% CI, 1.59 to 3.91), mycophenolate mofetil (MMF) use (OR, 2.83; 95% CI, 1.59 to 5.03), cyclophosphamide (CYC) use (OR, 3.35; 95% CI, 2.47 to 4.54), biologics use (OR, 3.43; 95% CI, 2.36 to 4.98), and lymphopenia (OR, 4.26; 95% CI, 2.08 to 8.73). Hydroxychloroquine (HCQ) use reduced risk of IFIs (OR, 0.67; 95% CI, 0.54 to 0.84). Furthermore, 17 of the 26 studies only reported risk factors for Pneumocystis jiroveci pneumonia (PJP) in patients with CTD. Pulmonary disease; ILD; and the use of GC, CNIs, CYC, methotrexate (MTX), MMF and biologics, and lymphopenia increased the risk of PJP, whereas the use of HCQ reduced its risk. CONCLUSION Diabetes, pulmonary disease, ILD, renal disease, use of GC (especially at moderate to high dose) and immunosuppressive drugs, and lymphopenia were found to be associated with significant risk for IFIs (especially PJP) in patients with CTD. Furthermore, the use of HCQ may reduce the risk of IFIs in patients with CTD.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China.
| | - Wenxuan Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xiaoyu Tang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ruiting Deng
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China
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5
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Lewis J, Östör AJK. The prevalence and impact of polypharmacy in rheumatology. Rheumatology (Oxford) 2023; 62:SI237-SI241. [PMID: 37871915 DOI: 10.1093/rheumatology/kead307] [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: 03/20/2023] [Accepted: 06/10/2023] [Indexed: 10/25/2023] Open
Abstract
Polypharmacy is increasingly common in rheumatology due to the complex nature of managing chronic autoimmune diseases. To date there has been limited research into the impact of polypharmacy on rheumatology patients. In this article we reviewed the literature to characterize the prevalence of polypharmacy and its effect on patients. In addition, we have highlighted some key drug-drug interactions to consider involving DMARDs as well as complementary and alternative medicines. There is emerging evidence demonstrating that polypharmacy contributes to adverse outcomes and alters treatment response. This association is best described in RA and is less clear in other patient cohorts. It is also unclear whether polypharmacy is directly harmful or just a surrogate marker for other factors affecting outcomes. Rheumatologists should be aware of the risk of polypharmacy as well as specific drug-drug interactions that can occur in managing chronic autoimmune disease.
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Affiliation(s)
- Justin Lewis
- Department of Rheumatology, Western Health, Melbourne, Victoria, Australia
| | - Andrew J K Östör
- Monash University, Cabrini Medical Centre, Melbourne, ANU, Canberra & Emeritus Research, Australia
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6
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Siegfried EC, Arkin LM, Chiu YE, Hebert AA, Callen JP, Castelo-Soccio L, Co DO, Cordoro KM, Curran ML, Dalrymple AM, Flohr C, Gordon KB, Hanna D, Irvine AD, Kim S, Kirkorian AY, Lara-Corrales I, Lindstrom J, Paller AS, Reyes M, Begolka WS, Tom WL, Van Voorhees AS, Vleugels RA, Lee LW, Davies OMT, Brandling-Bennett HA. Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines. Pediatr Dermatol 2023; 40:789-808. [PMID: 37316462 DOI: 10.1111/pde.15327] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/26/2023] [Indexed: 06/16/2023]
Abstract
Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication.
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Affiliation(s)
- Elaine C Siegfried
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lisa M Arkin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yvonne E Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adelaide A Hebert
- UTHealth McGovern Medical School at Houston, Houston, Texas, United States
| | - Jeffrey P Callen
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Leslie Castelo-Soccio
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic O Co
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Megan L Curran
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Austin M Dalrymple
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Carsten Flohr
- Department of Paediatric Dermatology, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ken B Gordon
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | - Susan Kim
- University of California, San Francisco, California, USA
| | - A Yasmine Kirkorian
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Children's National Hospital, Washington, DC, USA
| | | | - Jill Lindstrom
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melissa Reyes
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | | | - Wynnis L Tom
- University of California, San Diego School of Medicine, San Diego, California, USA
- Rady Children's Hospital-San Diego, San Diego, California, USA
| | | | - Ruth Ann Vleugels
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Wine Lee
- Medical University of South Carolina, Charleston, South Carolina, USA
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7
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[Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search]. Z Rheumatol 2023; 82:151-162. [PMID: 36633662 DOI: 10.1007/s00393-022-01308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 01/13/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective specialist subject information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
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8
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DHA Induces Cell Death through the Production of ROS and the Upregulation of CHOP in Fibroblast-like Synovial Cells from Human Rheumatoid Arthritis Patients. Int J Mol Sci 2023; 24:ijms24021734. [PMID: 36675245 PMCID: PMC9865349 DOI: 10.3390/ijms24021734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/29/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
Rheumatoid arthritis (RA) is an inflammatory disease marked by a massive proliferation of synovial cells in the joints. In this study, we investigated the pro-apoptotic effects of docosahexaenoic acid (DHA) in human fibroblast-like synovial cells from RA patients (RA-FLS). An in vitro study using MH7A cells showed that DHA treatment induced caspase-8-dependent apoptosis in a dose-dependent manner and reduced the TNF-α-mediated induction of MMP-9 and IL-1β. DHA also induced the phosphorylation of eIF2α, the expression of the ER stress markers ATF4 and C/EBP homologous protein (CHOP), and death receptor 5 (DR5). The knockdown of CHOP or DR5 increased cell viability and reduced apoptosis in DHA-treated cells. Furthermore, the knockdown of CHOP reduced DHA-mediated DR5 expression, while the overexpression of CHOP increased DR5 expression. We also found that DHA treatment induced the accumulation of reactive oxygen species (ROS), and pretreatment with the anti-oxidant Tiron effectively abrogated not only the expression of CHOP and DR5, but also DHA-induced apoptosis. Under this condition, cell viability was increased, while PARP-1 cleavage and caspase-8 activation were reduced. All the findings were reproduced in human primary synovial cells obtained from RA patients. These results suggest that the DHA-mediated induction of ROS and CHOP induced apoptosis through the upregulation of DR5 in RA-FLSs, and that CHOP could be used as a therapy for RA.
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9
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[Nephrological management and drug dosing in patients with rheumatic diseases and renal insufficiency]. Z Rheumatol 2022; 81:811-828. [PMID: 36350405 DOI: 10.1007/s00393-022-01283-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND In patients with inflammatory rheumatic diseases and renal insufficiency there are two challenges for physicians: to adapt the antirheumatic medication to the renal function and to carry out a nephroprotective treatment that prevents long-term deterioration of renal function and reduces the elevated cardiovascular risk. METHODS A literature search (in PubMed) was carried out and the current state of knowledge on nephroprotective treatment strategies and the treatment of rheumatic diseases in the presence of renal insufficiency was collated, evaluated and summarized. RESULTS Lifestyle interventions, especially the cessation of smoking and drug treatment strategies form the basis of nephroprotection including the control of diabetes mellitus with metformin, sodium glucose transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP1) analogues and control of hypertension with blockade of the renin-angiotensin-aldosterone system (RAAS), hyperlipidemia, hyperphosphatemia and metabolic acidosis. The SGLT2 inhibitors are also effective for nondiabetic nephropathy. The elevated cardiovascular risk is further reduced by effective control of inflammatory rheumatic activity. Numerous conventional disease modifying antirheumatic drugs, especially methotrexate and the Janus kinase (JAK) inhibitors baricitinib and filgotinib, must mostly be adapted to the renal function. In contrast, biologics can be given in standard doses with the exception of anakinra. The increased cardiovascular risk currently limits the use of tofacitinib in patients with renal insufficiency. CONCLUSION The antirheumatic medication should be modified and a complex nephroprotective treatment concept is mandatory in the management of patients with rheumatic disease and renal insufficiency, that in the best-case scenario can be guaranteed by a close interdisciplinary cooperation of rheumatologists and nephrologists.
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10
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Ouellette S, Shah R, Razi S, Ashforth G, Wassef C. Fatal low-dose methotrexate toxicity: A case report and literature review. Dermatol Ther 2022; 35:e15945. [PMID: 36259229 DOI: 10.1111/dth.15945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/01/2022]
Abstract
Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis. Here, we report a case of a 67-year-old male with a past medical history of end stage renal disease on peritoneal dialysis and moderate-to-severe psoriasis with psoriatic arthritis presented with abdominal pain, diarrhea, rash, mucositis, and mucocutaneous ulcers and erosions. The patient was taking methotrexate 10 mg weekly without folic acid supplementation and was found to be pancytopenic. Despite treatment, the patient developed multiorgan failure and passed away after 16 days of hospitalization. Myelosuppression is considered the most serious side effect with the highest risk of mortality. Risk factors for toxicity include renal insufficiency, advanced age, lack of folate supplementation, drug interactions, and medication errors. Importantly, serum levels of MTX do not correlate with toxicity; therefore, folinic acid rescue therapy should be started as soon as MTX toxicity is suspected. MTX toxicity is rare with low dose, proper dose scheduling, and adherence to the recommended guidelines. It is imperative that physicians considering therapy with low dose MTX for dermatologic indications take into consideration a patient's risk factors for toxicity and monitor appropriately.
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Affiliation(s)
- Samantha Ouellette
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Rohan Shah
- Division of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Gina Ashforth
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Cindy Wassef
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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11
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Di Cesare A, Ricceri F, Rosi E, Fastame MT, Prignano F. Therapy of PsO in Special Subsets of Patients. Biomedicines 2022; 10:2879. [PMID: 36359399 PMCID: PMC9687729 DOI: 10.3390/biomedicines10112879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 01/02/2024] Open
Abstract
Psoriasis is a chronic, inflammatory skin disease that may occur at any age, with a bimodal peak of incidence around the age of 16-20 years of age (early onset) and 57-60 years (late-onset). It is estimated that roughly 70% of patients develop the disease before the age of 40, which coincides with the reproductive years. Moreover, psoriasis is a chronic disease, meaning that, with increased life-duration expectancy, the number of patients affected with psoriasis aged over 65 years is going to increase and represent a big therapeutic challenge. Actually, no specific drug recommendation is available, based only on the age of the patients, while therapeutic prescription should take into account that elderly patients have more comorbidities than younger patients, with polypharmacy and an increased risk of drug interactions. Women with psoriasis are more likely to report a worse influence of the disease on their quality of life, and they are more susceptible to the development of depression. Furthermore, pregnancy and lactation represent a major contraindication to several systemic agents, and only a few studies exist providing the safety of certain drugs during these periods of life of a woman, such as certolizumab pegol. In this paper, we discuss systemic therapeutic strategies, including conventional and biological therapies, in a special subset of patients affected with moderate-to-severe psoriasis focusing on elderly patients and on female patients in fertile age, pregnancy, and lactation.
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Affiliation(s)
| | | | | | | | - Francesca Prignano
- Department of Health Sciences, Section of Dermatology, University of Florence, 50125 Florence, Italy
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12
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Hong SJ, Galati J, Katz S. Crohn's Disease of the Elderly: Unique Biology and Therapeutic Efficacy and Safety. Gastroenterol Clin North Am 2022; 51:425-440. [PMID: 35595423 DOI: 10.1016/j.gtc.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is increasing in the elderly population. Compared with patients with onset during younger years, patients with elderly-onset IBD have a distinct clinical presentation, disease phenotype, and natural history. Genetics contribute less to pathogenesis of disease, whereas aging-related biological changes, such as immunosenescence and dysbiosis, are associated with elderly-onset IBD. Frailty is an increasingly recognized predictor of adverse outcomes. As an increasingly wider array of biologic and small molecule therapeutic options becomes available, data regarding efficacy and safety of these agents in patients are paramount given the unique characteristics of this population.
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Affiliation(s)
- Simon J Hong
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA.
| | - Jonathan Galati
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA
| | - Seymour Katz
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA
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13
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Co-treatment of Nimbolide augmented the anti-arthritic effects of methotrexate while protecting against organ toxicities. Life Sci 2022; 295:120372. [PMID: 35143824 DOI: 10.1016/j.lfs.2022.120372] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 02/07/2023]
Abstract
Prolonged exposure to the pharmacological doses of disease-modifying anti-rheumatic drugs (DMARDs) often results in major organ toxicities resulting in poor patient compliance. Methotrexate (MTX) is one of the commonly prescribed DMARDs for the treatment of arthritis, which results in vital organ dysfunction. To retain the anti-arthritic activity of MTX with the reduction in toxicities, combination therapies are warranted. Nimbolide (NMB) is a potent anticancer, anti-inflammatory and anti-fibrotic agent whose potential has been demonstrated in various pre-clinical models. Monoarthritis was developed with Complete Freund's Adjuvant in the knees of Wistar rats and treatment was given with either NMB (3 mg/kg/day) or MTX (2 mg/kg/week) alone or combination therapy (NMB + MTX). The anti-arthritic effects were evaluated by arthritic scoring, radiological imaging, synovial tissue proteins analysis, and histopathological staining. While hepato-renal toxicity was assessed in serum by evaluating the kidney and liver functional parameters, in tissues by oxidative-nitrosative stress markers, and pro-inflammatory cytokines levels. Histopathological analysis was performed to study the extent of tissue damage. Molecular studies like immunoblotting and immunohistochemistry were performed to understand the effect of combination therapy. We thereby report that monotherapy with either NMB or MTX exhibited significant anti-arthritic effects, while combination therapy resulted in augmented anti-arthritic effects with significant reduction in hepato-renal toxicity produced by MTX probably through anti-inflammatory and anti-oxidant effects. Therefore, our proposed combination of NMB and MTX may serve as a potential strategy for the effective management of arthritis.
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14
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Venner JM, Bernstein CN. Immunomodulators: still having a role? Gastroenterol Rep (Oxf) 2022; 10:goac061. [PMID: 36381225 PMCID: PMC9642324 DOI: 10.1093/gastro/goac061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/08/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022] Open
Abstract
Immunomodulators, particularly the thiopurines and to a lesser extent methotrexate, were standard of care for inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis, for >40 years. While there has been a renaissance in available therapies with the advent of biologics and small molecules, an impetus remains for the ongoing use of thiopurines and methotrexate. This is particularly true for the maintenance of remission and when used in combination therapy with infliximab to suppress anti-biologic antibodies. This article summarizes the data behind immunomodulator use in Crohn’s disease, focusing on the beneficial role these drugs still have while acknowledging their clinical limitations.
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Affiliation(s)
- Jeffery M Venner
- University of Manitoba IBD Clinical and Research Centre , Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre , Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Manitoba, Canada
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15
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Inokuma S. Search of official nationwide database in Japan for adverse events associated with disease-modifying antirheumatic drug therapies: focus on therapies in combination with methotrexate. Expert Opin Drug Saf 2021; 21:573-580. [PMID: 34762577 DOI: 10.1080/14740338.2022.2006180] [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: 02/07/2023]
Abstract
BACKGROUND Disease-modifying antirheumatic drugs (DMARDs) are essential for rheumatoid arthritis (RA) therapy. The adverse events (AEs) evaluation should focus on that methotrexate (MTX) is frequently prescribed in combination with others (combination MTX). METHODS A search of the website of the official Japanese Agency for AEs, including lymphoproliferative disease (LPD), cytopenia, interstitial pneumonia, infectious pneumonia other than Pneumocystis jirovecii pneumonia (PCP) (i-Pn), and PCP, associated with MTX, tacrolimus, adalimumab, tocilizumab, and abatacept therapies reported from 2014 to 2016 was performed. Number of each AE cases and its ratio to total number of AEs cases were examined. Combination MTX was checked for RA cases. RESULTS A total of 8874 cases were listed. In 3955 MTX cases, LPD was most frequent (36.4%). In any of the other four DMARDs cases, i-Pn was most frequent (4.2~15.3%); PCP cases showed most frequent combination MTX (94.4%). In total, including cases reported for MTX therapy, 98.2% of LPD and 97.6% of PCP cases had MTX, and less than 90% of the other AEs cases had MTX. CONCLUSION LPD was by far the most frequent AE associated with MTX therapy. PCP was strongly associated with combination MTX. For any of the other four DMARDs, i-Pn was most frequent.
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Affiliation(s)
- Shigeko Inokuma
- Chiba Central Medical Center; National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
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16
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Mitsuboshi S, Niimura T, Kanda M, Ishida S, Zamami Y, Ishizawa K. Risk of Hematologic Events With Coadministration of Methotrexate and the Breast Cancer Resistance Protein Inhibitor Febuxostat. Ann Pharmacother 2021; 56:910-915. [PMID: 34726078 DOI: 10.1177/10600280211055794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The breast cancer resistance protein (BCRP) is a key drug transporter found in the liver, kidney, central nervous system, and gastrointestinal tract. Due to the wide expression of BCRP, interactions of other drugs with methotrexate (MTX) may differ in oral and intravenous MTX users, and understanding of these interactions may be useful in preventing severe adverse events. Febuxostat, a urate-lowering drug, inhibits BCRP. OBJECTIVE The objective of this study was to clarify the differences in the drug-drug interaction profiles of oral and intravenous methotrexate, associated with BCRP. METHODS We analyzed the Japanese Adverse Drug Event Report database and compared the frequency of hematologic events in patients taking oral and intravenous MTX, with or without the concomitant use of febuxostat or allopurinol. Hematologic events were defined as pancytopenia and neutropenia. Multiple logistic regression analysis was then used to identify the risk factors for hematologic events in oral and intravenous MTX users. RESULTS We identified 8 453 oral and 810 intravenous MTX users with 546 and 126 cases of hematologic events, respectively. Compared with those not using febuxostat, a disproportionate number of hematologic events was observed in intravenous MTX users concomitantly using febuxostat (P < 0.01). The multivariate logistic analysis of intravenous MTX users showed that hematologic events were significantly associated with febuxostat use (P < 0.01) and age ≥ 60 years (P < 0.01). CONCLUSION AND RELEVANCE Our findings suggest that patients being treated with intravenous MTX who concomitantly use febuxostat may be at an increased risk of hematologic events, presumably due to BCRP-mediated drug-drug interaction.
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Affiliation(s)
| | - Takahiro Niimura
- Department of Clinical Pharmacology & Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Masaya Kanda
- Department of Clinical Pharmacology & Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Shunsuke Ishida
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology & Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Keisuke Ishizawa
- Department of Clinical Pharmacology & Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
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17
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Drozdzik M, Drozdzik M, Oswald S. Membrane Carriers and Transporters in Kidney Physiology and Disease. Biomedicines 2021; 9:biomedicines9040426. [PMID: 33919957 PMCID: PMC8070919 DOI: 10.3390/biomedicines9040426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
The growing information suggests that chronic kidney disease may affect expression and function of membrane carriers and transporters in the kidney. The dysfunction of carriers and transporters entails deficient elimination of uremic solutes as well as xenobiotics (drugs and toxins) with subsequent clinical consequences. The renal carriers and transporters are also targets of drugs used in clinical practice, and intentional drug-drug interactions in the kidney are produced to increase therapeutic efficacy. The understanding of membrane carriers and transporters function in chronic kidney disease is important not only to better characterize drug pharmacokinetics, drug actions in the kidney, or drug-drug interactions but also to define the organ pathophysiology.
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Affiliation(s)
- Marek Drozdzik
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University, 70-111 Szczecin, Poland
- Correspondence:
| | - Maria Drozdzik
- Faculty of Medicine, Medical University of Lodz, 90-419 Lodz, Poland;
| | - Stefan Oswald
- Institute of Pharmacology and Toxicology, Rostock University Medical Center, 18051 Rostock, Germany;
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18
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Wohlrab J, Mrowietz U, Weidinger S, Werfel T, Wollenberg A. [Recommendations when switching therapy from immunosuppressive drugs to dupilumab in patients with atopic dermatitis]. DER HAUTARZT 2021; 72:321-327. [PMID: 33175219 PMCID: PMC8016796 DOI: 10.1007/s00105-020-04720-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Based on new insights into the molecular pathogenesis of atopic dermatitis, a targeted anti-inflammatory therapy-dupilumab-has recently been approved as treatment alongside glucocorticoids and ciclosporin. Due to their pharmacology, neither glucocorticoids nor ciclosporin nor the off label used substances methotrexate, azathioprine and mycophenolic acid derivatives are suitable for long-term therapy. When switching therapy from small molecular substances to dupilumab, various factors should be considered. Both the specific cause of the change (ineffectiveness, adverse effects or contraindications) as well as the pharmacological conditions should be taken into account. Since there have been no specific clinical studies on this subject so far, the authors relied mainly on a literature search to draw up recommendations for practical everyday use.
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Affiliation(s)
- Johannes Wohlrab
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland.
- An-Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle-Wittenberg, Deutschland.
| | - Ulrich Mrowietz
- Klinik für Dermatologie, Venerologie und Allergologie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Stephan Weidinger
- Klinik für Dermatologie, Venerologie und Allergologie, Christian-Albrechts-Universität Kiel, Kiel, Deutschland
| | - Thomas Werfel
- Klinik für Dermatologie und Allergologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Andreas Wollenberg
- Klinik für Dermatologie und Allergologie, Ludwig-Maximilian-Universität München, München, Deutschland
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19
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Mitsuboshi S. Risk of haematological events and preventive effect of folic acid in methotrexate users with chronic kidney disease and rheumatoid arthritis: Analysis of the Japanese Adverse Drug Event Report database. Br J Clin Pharmacol 2020; 87:2286-2289. [PMID: 33179261 DOI: 10.1111/bcp.14641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 11/28/2022] Open
Abstract
Although methotrexate (MTX) for rheumatoid arthritis (RA) sometimes causes severe haematological toxicities in users with chronic kidney disease (CKD), data are limited regarding the risk of these events and the preventive effect of folic acid. This study evaluated the risk of haematological toxicities and the efficacy of folic acid in MTX users with CKD using the Japanese Adverse Drug Event Report. In total, 5,648 oral MTX users with RA were identified, including 630 with haematological toxicities. MTX users with CKD had significantly increased risk of haematological toxicities compared with those without CKD when folic acid was not used (OR 3.72; 95% CI 2.87-4.81; P < 0.01). Multivariate logistic analysis showed that the risk of haematological toxicities was significantly decreased by only folic acid (OR 0.16; 95% CI 0.04-0.62; P < 0.01). This result provides useful information for preventing severe haematological toxicities in MTX users with CKD and RA.
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20
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Amissah-Arthur MB, Baah W. Methotrexate-Induced Pancytopenia and Mucositis Caused by Medication Error. Ghana Med J 2020; 54:68-71. [PMID: 32863415 PMCID: PMC7445697 DOI: 10.4314/gmj.v54i1.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of methotrexate in routine clinical practice is becoming more common among specialties such as rheumatology, dermatology, oncology and obstetrics. General clinicians are increasingly encountering patients on this drug. Though it has a high safety profile, there is a recognised risk of acute toxicity or long-term complications associated with its use, which can be worsened by several factors such as advanced age, moderate to severe renal impairment, low folate level and/or inadequate folate supplementation, hypoalbuminaemia, polypharmacy causing drug-drug interactions and wrongful administration. We present a case of a 45-year old woman with rheumatoid arthritis who presented with acute pancytopaenia and mucositis due to methotrexate toxicity. We highlight its peculiar dosing regimen to minimise prescribing errors.
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Affiliation(s)
| | - Winifred Baah
- Korle Bu Teaching Hospital, Department of Medicine and Therapeutics, Accra, Ghana
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21
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Vela Casasempere P, Ruiz Torregrosa P, García Sevila R. Pneumocystis jirovecii in immunocompromised patients with rheumatic diseases. ACTA ACUST UNITED AC 2020; 17:290-296. [PMID: 32466869 DOI: 10.1016/j.reuma.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/30/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
Infections, including opportunistic infections, are a major and frequent cause of morbidity and mortality in patients with systemic autoimmune and rheumatic diseases. Pneumocystis jirovecii pneumonia, classically considered to be typical of HIV patients, transplanted patients or patients treated with oncological chemotherapy, is appearing increasingly frequently in these patients. Therefore, rheumatologists should know its mechanism of production, clinical manifestations, treatment and prophylaxis, all of which are addressed in this review.
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Affiliation(s)
- Paloma Vela Casasempere
- Sección de Reumatología. Hospital General Universitario de Alicante. ISABIAL, Alicante, España; Universidad Miguel Hernández, Alicante, España.
| | | | - Raquel García Sevila
- Servicio de Neumología. Hospital General Universitario de Alicante, Alicante, España
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22
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Havele SA, Ellis A, Chaitoff A, Khanna U, Parambil J, Langford CA, Fernandez AP. Safety of trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia prophylaxis in patients taking methotrexate. J Am Acad Dermatol 2020; 84:166-168. [PMID: 32320772 DOI: 10.1016/j.jaad.2020.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sonia A Havele
- Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ariana Ellis
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Alex Chaitoff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Urmi Khanna
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Joseph Parambil
- Department of Pulmonology, Allergy & Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Langford
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Cleveland, Ohio
| | - Anthony P Fernandez
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio.
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Pflugbeil S, Böckl K, Pongratz R, Leitner M, Graninger W, Ortner A. Drug interactions in the treatment of rheumatoid arthritis and psoriatic arthritis. Rheumatol Int 2020; 40:511-521. [PMID: 32052146 DOI: 10.1007/s00296-020-04526-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treating patients with inflammatory joint diseases (rheumatoid arthritis, psoriatic arthritis) according to established treatment algorithms often requires the simultaneous use of three or more medications to relieve symptoms and prevent long-term joint damage as well as disability. OBJECTIVE To assess and give an overview on drug-drug interactions in the pharmacotherapy of inflammatory joint diseases with regards to their clinical relevance. METHODS All possible drug combinations were evaluated using three commercially available drug interaction programs. In those cases where only limited/no data were found, a comprehensive hand search of Pubmed was carried out. Finally, the drug-drug interactions of all possible combinations were classified according to evidence-based medicine and a specifically generated relevance-based system. RESULTS All three interaction software programs showed consistent results. All detected interactions were combined in clearly structured tables. CONCLUSION A concise overview on drug-drug interactions is given. Especially in more sophisticated cases extensive knowledge of drug interactions supports optimisation of therapy and results in improved patient safety.
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Affiliation(s)
- Stephan Pflugbeil
- Division of Rheumatology, ÖGK Outpatient Department of Graz, 8010, Graz, Austria
| | - Karin Böckl
- Institute of Pharmaceutical Sciences, University of Graz, 8010, Graz, Austria
| | - Reinhold Pongratz
- Division of Rheumatology, ÖGK Outpatient Department of Graz, 8010, Graz, Austria
| | - Marianne Leitner
- Hospital Pharmacy, Medical University of Graz, 8036, Graz, Austria
| | - Winfried Graninger
- Department of Rheumatology, Medical University of Graz, 8036, Graz, Austria
| | - Astrid Ortner
- Institute of Pharmaceutical Sciences, University of Graz, 8010, Graz, Austria.
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Treatment of Medicare Patients with Moderate-to-Severe Psoriasis who Cannot Afford Biologics or Apremilast. Am J Clin Dermatol 2020; 21:109-117. [PMID: 31452091 DOI: 10.1007/s40257-019-00468-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Elderly patients are a group with a high frequency of psoriasis. Their disease burden has negative impacts on their quality of life. While there is a clear need to treat these patients, there are challenges in doing so. This work seeks to define the challenges that exist in treating elderly Medicare patients, as well as to provide treatment suggestions for providers to follow if they encounter one or more of these challenges. Providers face the following challenges when creating treatment plants for elderly patients with psoriasis: difficulty in obtaining drug coverage through Medicare, increased medical comorbidities, and polypharmacy. Providers aim for regimens that are affordable, safe, and efficacious, but it is not always clear how to achieve this combination, especially in elderly Medicare patients. This work is relevant in that it aims to explain the logistical roadblocks posed by Medicare coverage and provide solutions for commonly encountered issues in the treatment of a disabling and common disease in a high-risk population. Specifically, alternative treatment options to biologics and small-molecule inhibitors are discussed and include topical therapies, phototherapy, methotrexate, acitretin, and cyclosporine and for psoriatic arthritis include corticosteroids and leflunomide. The specific risks and benefits of these therapies in the elderly population are provided, allowing providers to make patient-specific decisions about optimal regimens.
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Odderskov C, Stengaard-Pedersen K, Ellingsen T, Hornung N. Methotrexate pharmacokinetic is influenced by co-administration of cyclosporin in rheumatoid arthritis patients. Results from a randomized clinical trial. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 80:185-190. [PMID: 31876200 DOI: 10.1080/00365513.2019.1706190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim was to investigate if the pharmacokinetics of methotrexate (MTX) are affected by the addition of cyclosporin (CsA). Forty patients diagnosed with early rheumatoid arthritis (RA) were included in this open prospective study: 20 patients were treated with a dose of 7.5 mg MTX and a dose of 2.5 mg/kg CsA, 20 patients were treated with a dose of 7.5 mg MTX and placebo. Baseline measurements of plasma MTX and erythrocyte MTX were made. Area under the plasma concentration versus time curve (AUC) and other pharmacokinetic variables were estimated by means of a population based software model. Clinical improvement of 20-50-70% according to the American College of Rheumatology (ACR) and adverse events were evaluated ongoing for 52 weeks. We found that mean peak plasma MTX concentration was significantly higher in the MTX + CsA combination treatment group (p = .003). No differences in AUC, erythrocyte MTX or other pharmacokinetic parameters were found between the two treatment groups. Estimated Glomerular Filtration Rate (eGFR) decreased significantly in the MTX + CsA treatment group (p < .001), but no serious adverse events occurred in either of the two groups. In conclusion, CsA added to methotrexate treatment in early RA significantly increased peak-plasma MTX concentration, but other pharmacokinetic parameters and measurements of MTX were unchanged.
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Affiliation(s)
- Caroline Odderskov
- Department of Clinical Biochemistry, Regional Hospital Randers, Randers, Denmark
| | | | - Torkell Ellingsen
- Rheumatology Research Unit, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Nete Hornung
- Department of Clinical Biochemistry, Regional Hospital West Jutland, Holstebro, Denmark
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26
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Lalevée S, Lebrun-Vignes B, Simon C, Laugier D, Fardet L. Cytopenia induced by low-dose methotrexate: An analysis of 433 cases from the French pharmacovigilance database. Eur J Intern Med 2019; 67:97-101. [PMID: 31350129 DOI: 10.1016/j.ejim.2019.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Up to 5% of individuals exposed to low-dose methotrexate (MTX) (i.e., ≤30 mg/week) may develop cytopenia. However, MTX-induced cytopenia have been poorly described. MATERIAL AND METHODS All cases of cytopenia (i.e., anaemia, leukopenia, thrombocytopenia, bi- or pancytopenia) in patients receiving low-dose MTX reported to the French pharmacovigilance database during 2006-2016 were analysed. Three groups were defined: cytopenia due to MTX medication errors (e.g., daily rather than weekly administration), cytopenia in people receiving several medications including MTX, cytopenia in people receiving only MTX. RESULTS 433 cases were analysed. Eighty-four cases (19.4%) were due to medication errors, 180 (41.6%) occurred in individuals exposed both to MTX and other drugs, and 169 (39.0%) occurred in individuals only exposed to MTX. By comparison to other patients, those with cytopenia due to medication errors were older (74 ± 13 vs 69 ± 15 years, p = 0.002), received more frequently MTX orally (92.9% vs 65.3%, p<0.001) and had more frequently pancytopenia (71.4% vs 54.4%, p = 0.005). By comparison to individuals exposed to multiple drugs (n = 180), those exposed only to MTX (n = 169) were older (71 ± 15 vs 67 ± 14, p = 0.02), and had more often pancytopenia (62.7% vs 46.7%, p = 0.001). Among those only exposed to MTX, most cases (n = 140, 82.8%) were considered as toxic rather than idiosyncratic reactions and a trigger (e.g. diarrhoea) was found in 59.3% of those cases. Overall 30 (6.9%) deaths occurred, including 8 in the "medication error" group and 8 in the "MTX only" group. CONCLUSION These data may be useful for defining optimal biological monitoring of patients prescribed low-dose MTX.
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Affiliation(s)
- Sophie Lalevée
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - Bénédicte Lebrun-Vignes
- Regional Pharmacovigilance Centre, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; EA 7379 EpiDermE, Université Paris Est Créteil, 94000 Créteil, France
| | - Corinne Simon
- Regional Pharmacovigilance Center Centre Val de Loire, CHRU Tours, 37000 Tours, France
| | - Delphine Laugier
- Regional Pharmacovigilance Centre of Marseille Provence Corse, Departement of clinical Pharmacology and Pharmacovigilance, AP-HM, 13000 Marseille, France
| | - Laurence Fardet
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France; EA 7379 EpiDermE, Université Paris Est Créteil, 94000 Créteil, France.
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27
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Lucas CJ, Dimmitt SB, Martin JH. Optimising low-dose methotrexate for rheumatoid arthritis-A review. Br J Clin Pharmacol 2019; 85:2228-2234. [PMID: 31276602 DOI: 10.1111/bcp.14057] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Methotrexate at low doses (5-25 mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.
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Affiliation(s)
- Catherine J Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Simon B Dimmitt
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Western Australia, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
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Arslan A, Zain MA, Mukhtar M, Ullah W, Roomi S. Methotrexate and doxycycline interaction: a rare cause of pancytopenia. BMJ Case Rep 2019; 12:12/5/e229296. [PMID: 31154348 DOI: 10.1136/bcr-2019-229296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Methotrexate (MTX) was originally formulated as one of the first antitumour drugs due to its ability to alter folate metabolism, which renders it to be an antiproliferative agent. Classically, the higher dosage is administered via parenteral route, in a cyclical fashion, to achieve antitumour effects. Patients on high doses of MTX are prone to develop rare complications of myelosuppression and pancytopenia, in a dose-dependent fashion, secondary to altered folate metabolism. 1 Herein, we present a unique case of rheumatoid arthritis presented with pancytopenia due to low-dose MTX and doxycycline drug interaction. We also report the successful management of pancytopenia and oral ulcers with combination therapy of leucovorin and granulocyte colony-stimulating factor.
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Affiliation(s)
- Ahmad Arslan
- Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Waqas Ullah
- Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Sohaib Roomi
- Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
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29
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Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 311] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
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Concomitant Administration of High-dose Methotrexate and Low-dose Aspirin Without Any Delay in Methotrexate Clearance in a Patient With Osteosarcoma: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2018; 40:e392-e393. [PMID: 28902079 DOI: 10.1097/mph.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Methotrexate (MTX) is a commonly used agent in the treatment of oncology patients whose clearance depends on renal health maintaining glomerular filtration and tubular secretion. Thus concomitant use of other drugs that utilize the same mechanism of clearance are generally avoided as this may contribute to increased MTX-associated toxicity. OBSERVATION Herein, we describe the use of low-dose aspirin with high-dose MTX in a patient with osteosarcoma. CONCLUSION Concomitant aspirin use did not affect the clearance of high-dose MTX and the patient did not experience any MTX-related toxicity including mucositis or renal impairment.
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31
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Leenders EKSM, Westdorp H, Brüggemann RJ, Loeffen J, Kratz C, Burn J, Hoogerbrugge N, Jongmans MCJ. Cancer prevention by aspirin in children with Constitutional Mismatch Repair Deficiency (CMMRD). Eur J Hum Genet 2018; 26:1417-1423. [PMID: 29904176 DOI: 10.1038/s41431-018-0197-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 12/16/2022] Open
Abstract
Constitutional MisMatch Repair Deficiency (CMMRD) is caused by homozygous or compound heterozygous germline variants in one of the mismatch repair (MMR) genes (MSH2, MSH6, PMS2, MLH1). This syndrome results in early onset colorectal cancer, leukemia and lymphoma, brain tumors and other malignancies. Children with CMMRD are at high risk of developing multiple cancers and cancer surveillance does not guarantee detection of cancer at a curable stage. The development of a preventive treatment strategy would be a major step forward. Long-term daily use of acetylsalicylic acid (ASA) has been shown to reduce cancer risk in individuals with Lynch syndrome (LS). LS is caused by heterozygous germline variants of MSH2, MSH6, PMS2 and MLH1 and characterized by an increased risk of developing colorectal and endometrial cancer at adult age. Here we discuss the potential use of ASA for cancer prevention in patients with CMMRD.
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Affiliation(s)
- Erika K S M Leenders
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jan Loeffen
- Department of Pediatric Oncology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Christian Kratz
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - John Burn
- Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Marjolijn C J Jongmans
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands. .,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.
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Hamid M, Lashari B, Ahsan I, Micaily I, Sarwar U, Crocetti J. A deadly prescription: combination of methotrexate and trimethoprim-sulfamethoxazole. J Community Hosp Intern Med Perspect 2018; 8:149-151. [PMID: 29915656 PMCID: PMC5998292 DOI: 10.1080/20009666.2018.1466598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 04/12/2018] [Indexed: 10/27/2022] Open
Abstract
Methotrexate (MTX) is a chemotherapeutic synthetic(s) phase cell cycle inhibitor, and its role has evolved as an immunological agent in autoimmune diseases like rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, etc. Trimethoprim-sulfamethoxazole (TS) is one of the most widely prescribed antibiotics commonly used for urinary tract infections, exacerbations of chronic bronchitis, traveler's diarrhea, and pneumocystis pneumonia. Both MTX and TS can have significantly overlapping side effects involving dermatologic, renal, and hematological systems, and the combination of these can be deadly. Our case is about the combination of MTX and TS that leads to mucocutaneous ulceration, leukopenia, and renal insufficiency. The purpose of this case is to increase awareness of potentially significant toxicity from the combination of MTX with TS. Abbreviations: MTX: methotrexate; TS: trimethoprim-sulfamethoxazole; ED: emergency department; IV: intravenous; GI: gastrointestinal; NSAIDs: nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- Mohsin Hamid
- Department of Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Bilal Lashari
- Department of Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Irfan Ahsan
- Department of Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Ida Micaily
- Department of Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Usman Sarwar
- Department of Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Joseph Crocetti
- Pulmonary and Critical Care, Abington Hospital-Jefferson Health, Abington, PA, USA
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Betancourt BY, Biehl A, Katz JD, Subedi A. Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheum Dis Clin North Am 2018; 44:371-391. [PMID: 30001781 DOI: 10.1016/j.rdc.2018.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.
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Affiliation(s)
- Blas Y Betancourt
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA.
| | - Ann Biehl
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, FDA, 10001 New Hampshire Avenue, Hillandale Building, 4th Floor Silver Spring, MD 20993, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
| | - Ananta Subedi
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
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Svanström H, Lund M, Melbye M, Pasternak B. Concomitant use of low-dose methotrexate and NSAIDs and the risk of serious adverse events among patients with rheumatoid arthritis. Pharmacoepidemiol Drug Saf 2018; 27:885-893. [PMID: 29797447 DOI: 10.1002/pds.4555] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 01/16/2018] [Accepted: 04/11/2018] [Indexed: 11/08/2022]
Abstract
PURPOSE Case reports and pharmacokinetic studies have suggested that concomitant use of low-dose methotrexate and nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with increased risk of methotrexate toxicity. This study aimed to investigate the risk of serious adverse events associated with concomitant use of low-dose methotrexate and NSAIDs, compared with use of methotrexate alone, among patients with rheumatoid arthritis. METHODS The study was conducted as a register-based cohort study in Denmark, 2004 to 2015, including episodes of concomitant use of methotrexate and NSAIDs (n = 21 536) and control episodes of use of methotrexate alone (n = 21 725). The primary outcome was the composite end point any serious adverse event, including liver toxicity, acute renal failure, and cytopenia. Secondary outcomes were the individual outcome components. Analyses were conducted using proportional-hazards regression, with adjustment using inverse-probability-of-treatment weighting based on propensity scores. RESULTS During follow-up, 110 cases of the primary outcome occurred during concomitant use of methotrexate and NSAIDs (unadjusted incidence rate 12.1 per 1000 person-years) and 129 during control episodes (11.0 per 1000 person-years). Concomitant use of methotrexate and NSAIDs was associated with a significantly increased risk of any serious adverse event (weighted hazard ratio 1.40; 95% CI, 1.07-1.82). In secondary analyses, concomitant use of methotrexate and NSAIDs was associated with a significantly increased risk of acute renal failure and cytopenia. CONCLUSIONS Concomitant use of low-dose methotrexate and NSAIDs was associated with a significantly increased risk of serious adverse events, expanding on the evidence base for current regulatory recommendations that advocate caution when low-dose methotrexate and NSAID are coprescribed.
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Affiliation(s)
- Henrik Svanström
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Marie Lund
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Björn Pasternak
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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35
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Pneumocystis Pneumonia and the Rheumatologist: Which Patients Are At Risk and How Can PCP Be Prevented? Curr Rheumatol Rep 2018; 19:35. [PMID: 28488228 DOI: 10.1007/s11926-017-0664-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Immunosuppressive therapy for connective tissue diseases (CTDs) is steadily becoming more intense. The resultant impairment in cell-mediated immunity has been accompanied by an increasing risk for opportunistic infection (OI). Pneumocystis pneumonia (PCP) has been recognized as an OI in patients with CTDs, but specific risk factors and precise indications for PCP prophylaxis remain poorly defined. This review was undertaken to update information on the risk of PCP in patients with CTDs and to examine current guidelines for PCP prophylaxis in this population. RECENT FINDINGS Data on the occurrence of PCP and indications for prophylaxis in patients with CTDs is sparse. Large systematic reviews did not incorporate patients with CTD secondary to the lack of randomized control trials. Upon reviewing guidelines published since 2015, prophylaxis for PCP is recommended only for patients with ANCA-positive vasculitis, specifically granulomatosis with polyangiitis (GPA), who are undergoing intense induction therapy. Evidence-based recommendations for the prophylaxis of PCP in patients with CTDs cannot be provided. There is expert consensus that PCP prophylaxis is warranted in patients with GPA undergoing induction therapy. Prophylaxis should perhaps also be considered for other CTD patients who are receiving similar intense immunosuppressive therapy especially if they are lymphopenic or have a low CD4 count.
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36
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Kostović K, Žužul K, Čeović R, Bukvić Mokos Z. Psoriasis in the mature patient: Therapeutic approach in the era of biologics. Clin Dermatol 2018; 36:222-230. [DOI: 10.1016/j.clindermatol.2017.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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37
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Lepist EI, Ray AS. Renal Transporter-Mediated Drug-Drug Interactions: Are They Clinically Relevant? J Clin Pharmacol 2017; 56 Suppl 7:S73-81. [PMID: 27385181 DOI: 10.1002/jcph.735] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 02/04/2023]
Abstract
The kidney, through the distinct processes of passive glomerular filtration and active tubular secretion, plays an important role in the elimination of numerous endobiotics (eg, hormones, metabolites), toxins, nutrients, and drugs. Renal transport pathways mediating active tubular secretion and reabsorption in the proximal tubule are complex, involving apical and basolateral transporters acting in concert. Detailed studies of the molecular mechanisms of net active tubular secretion have established the involvement of multiple transporters with overlapping substrate specificity mediating competing secretion and reabsorption pathways. Although drug interactions arising from inhibition of renal transporters are rare relative to other mechanisms, they can involve commonly administered drugs (eg, cimetidine, metformin), may be underappreciated due to muted effects on plasma pharmacokinetics relative to tissue levels, can affect narrow-therapeutic-index medications (eg, antiarrhythmic, oncology medications), and may disproportionately affect sensitive populations where polypharmacy is common (eg, the elderly, diabetics). In particular, there is the potential for larger-magnitude interactions in subjects with reduced glomerular filtration rates due to the increased relative contribution of tubular secretion. The assessment of additional endpoints in drug-drug interaction studies including pharmacodynamics, positron emission tomography imaging, and metabolomics promises to expand our understanding of the clinical relevance of renal drug interactions.
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Affiliation(s)
- Eve-Irene Lepist
- Department of Drug Metabolism, Gilead Sciences, Inc, Foster City, California
| | - Adrian S Ray
- Department of Drug Metabolism, Gilead Sciences, Inc, Foster City, California
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38
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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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39
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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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40
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Ajmani S, Preet Singh Y, Prasad S, Chowdhury A, Aggarwal A, Lawrence A, Misra R, Mishra R, Agarwal V. Methotrexate-induced pancytopenia: a case series of 46 patients. Int J Rheum Dis 2017; 20:846-851. [PMID: 28261918 DOI: 10.1111/1756-185x.13004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIM Methotrexate (MTX) has the potential to cause serious adverse reactions and even mortality. We analyzed the predisposing factors and outcome in patients with MTX-induced pancytopenia admitted into our unit from 1996 to 2015. METHODS Patients were identified by departmental database search. Pancytopenia was defined as white blood cell count (WBC) < 3500 cells/mm3 , hemoglobin (Hb) < 11 g/dL and platelet count < 150 000 cells/mm3 . Severe pancytopenia was defined as WBC < 2000 cells/mm3 , Hb < 10 g/dL and platelet count < 50 000 cells/mm3 . RESULTS Forty-six patients were included in the study (female = 35). Twenty-four had been under the care of either primary care physicians or orthopedic surgeons and presented to us with pancytopenia. Sixteen patients had severe pancytopenia. Disease distribution was as follows: rheumatoid arthritis 33, psoriasis eight, systemic sclerosis two and others three. The median dose of MTX was 10 mg/week and median duration of treatment was 11 months. The median cumulative dose was 750 mg. Symptoms at presentation included: oral mucositis (n = 37); fever (n = 24); diarrhea (n = 12), bleeding gums (n = 5) and purpura (n = 3). The potential risk factors were: hypoalbuminemia (n = 23), renal insufficiency (n = 14), dosing errors (n = 13) and non-supplementation of folates (n = 7). Thirteen patients died. WBC at admission was found to determine survival (P < 0.05). CONCLUSION In patients on MTX, oral mucositis and fever can herald pancytopenia. MTX-induced pancytopenia is associated with high mortality. WBC at admission is the most important prognostic factor. There is need for increased awareness among physicians to minimize prescribing errors. A national guideline on monitoring of patients on MTX is desirable.
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Affiliation(s)
- Sajal Ajmani
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Yogesh Preet Singh
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Shiva Prasad
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Abhra Chowdhury
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Able Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ramnath Misra
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Richa Mishra
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Biehl AJ, Katz JD. Pharmacotherapy Pearls for the Geriatrician: Focus on Oral Disease-Modifying Antirheumatic Drugs Including Newer Agents. Clin Geriatr Med 2016; 33:1-15. [PMID: 27886691 DOI: 10.1016/j.cger.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Providing safe and effective pharmacotherapy to the geriatric patients with rheumatological disorders is an ongoing struggle for the rheumatologist and geriatrician alike. Cohesive communication and partnership can improve the care of these patients and subvert adverse outcomes. Disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the newest oral agent for treatment of rheumatoid arthritis, tofacitinib, have distinctive monitoring and adverse effect profiles. This article provides the general practitioner or geriatrician with clinically relevant pearls regarding the use of these interventions in older patients.
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Affiliation(s)
- Ann J Biehl
- Department of Pharmacy, National Institutes of Health Clinical Center, 10 Center Drive, Room 1C240, Bethesda, MD 20892-1196, USA.
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 6N-216F, Building 10, 9000 Rockville Pike, Bethesda, MD 20892, USA
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Hall JJ, Bolina M, Chatterley T, Jamali F. Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors. Ann Pharmacother 2016; 51:163-178. [DOI: 10.1177/1060028016672035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. Data Sources: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. Study Selection and Data Extraction: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. Data Synthesis: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. Conclusion: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.
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43
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Ahmed O, Nguyen GC. Therapeutic challenges of managing inflammatory bowel disease in the elderly patient. Expert Rev Gastroenterol Hepatol 2016; 10:1005-10. [PMID: 27087144 DOI: 10.1080/17474124.2016.1179579] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The rapid advancements in the management of inflammatory bowel disease (IBD) have given clinicians many new therapeutic options. The prevalence of IBD in the elderly is increasing, and the role of these therapeutic agents in the elderly population with IBD is still uncertain. AREAS COVERED In this review, we will highlight the challenges facing clinicians managing IBD in the elderly, the considerations to take when starting new medications, when to consider for surgical referral, the potential pitfalls to avoid, and the non-pharmacological management measures that clinicians should be aware of. Expert Commentary: The safety of prescribing new IBD medications in elderly patients must be taken into consideration. Managing comorbidities, polypharmacy, functional status and drug interactions can also be challenging and requires an individualized approach.
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Affiliation(s)
- Osman Ahmed
- a Mount Sinai Hospital Centre for Inflammatory Bowel Disease , University of Toronto , Toronto , Canada
| | - Geoffrey C Nguyen
- a Mount Sinai Hospital Centre for Inflammatory Bowel Disease , University of Toronto , Toronto , Canada
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44
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Prophylactic Trimethoprim-Sulfamethoxazole Does Not Affect Pharmacokinetics or Pharmacodynamics of Methotrexate. J Pediatr Hematol Oncol 2016; 38:449-52. [PMID: 27322715 PMCID: PMC4955728 DOI: 10.1097/mph.0000000000000606] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Trimethoprim-sulfamethoxazole (TMP/SMX) is used as prophylaxis against Pneumocystis jiroveci during chemotherapy. Many groups recommend withholding TMP/SMX during high-dose methotrexate (HDMTX) for concerns that it will delay methotrexate clearance. We compared methotrexate exposure following HDMTX (NCT00549848) in 424 patients including 783 courses that were given concurrently and 602 courses that were not given concurrently with TMP/SMX. Among 176 patients (555 courses) on the low-risk arm (HDMTX=2.5 g/m/24 h), there was no difference in clearance (110.7 [1.8%] vs. 108.2 [0.9%] mL/min/m, P=0.3) nor in 42 hour methotrexate concentration (0.37 [5.1%] vs. 0.40 (5.0%) μM, P=0.23). Among 248 patients (830 courses) on the standard/high-risk arm (HDMTX ~5 g/m/24 h), there was slightly higher clearance (95.5 [1.4%] vs. 91.2 [0.8%] mL/min/m, P=0.005) in those receiving TMP/SMX, with no difference in the 42 hour methotrexate concentration (0.59 [4.1%] vs. 0.66 [4.2%] μM, P=0.06). There was no difference in neutrophil counts based on TMP/SMX during HDMTX (P=0.83). TMP/SMX also did not have a significant impact on myelosuppression of low-dose methotrexate (40 mg/m) given during continuation therapy among 230 patients enrolled on a prior study (NCT00137111). Thus, we found no evidence for an interaction between methotrexate and TMP/SMX given prophylactically.
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John ES, Katz K, Saxena M, Chokhavatia S, Katz S. Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2016; 14:285-304. [PMID: 27387455 DOI: 10.1007/s11938-016-0099-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT A substantial and growing proportion of patients with inflammatory bowel disease (IBD) are elderly, and these patients require tailored treatment strategies. However, significant challenges exist in the management of this population due to the paucity of data. Establishing the initial diagnosis and assessing the etiology of future symptoms and flares can be challenging as several other prevalent diseases can masquerade as IBD, such as ischemic colitis, diverticular disease, and infectious colitis. Important pharmacologic considerations include reduced glomerular filtration rate and drug-drug interactions in the elderly. No drug therapy is absolutely contraindicated in this population; however, special risk and benefit assessments should be made. Older patients are more susceptible to side effects of steroids such as delirium, fractures, and cataracts. Budesonide can be an appropriate alternative for mild to moderate ulcerative colitis (UC) or Crohn's disease (CD) as it has limited systemic absorption. Pill size and quantity, nephrotoxicity, and difficulty of administration of rectal preparations should be considered with 5-aminosalicylic (5-ASA) therapy. Biologics are very effective, but modestly increase the risk of infection in a susceptible group. Based on their mechanisms, integrin receptor antagonists (e.g., vedolizumab) may reduce these risks. Use of antibiotics for anorectal or fistulizing CD or pouchitis in UC increases the risk of Clostridium difficile infection. Pre-existing comorbidities, functional status, and nutrition are important indicators of surgical outcomes. Morbidity and mortality are increased among IBD patients undergoing surgery, often due to postoperative complications or sepsis. Elderly adults with IBD, particularly UC, have very high rates of venous thromboembolism (VTE). Colonoscopy appears safe, but the optimal surveillance interval has not been well defined. Should the octogenarian, nonagenarian, and centurion undergo colonoscopy? The length of surveillance should likely account for the individual's overall life expectancy. Specific health maintenance should emphasize administering non-live vaccines to patients on thiopurines or biologics and regular skin exams for those on thiopurines. Smoking cessation is crucial to overall health and response to medical therapy, even among UC patients. This article will review management of IBD in the elderly.
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Affiliation(s)
- Elizabeth S John
- Department of Internal Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA. .,Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA.
| | - Kristina Katz
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Mark Saxena
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Sita Chokhavatia
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Seymour Katz
- New York University School of Medicine, 1000 Northern Blvd, Great Neck, NY, 11020, USA
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Factors Associated with Myelosuppression Related to Low-Dose Methotrexate Therapy for Inflammatory Rheumatic Diseases. PLoS One 2016; 11:e0154744. [PMID: 27128679 PMCID: PMC4851368 DOI: 10.1371/journal.pone.0154744] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/18/2016] [Indexed: 12/12/2022] Open
Abstract
Objective Severe myelosuppression is a serious concern in the management of rheumatic disease patients receiving methotrexate (MTX) therapy. This study was intended to explore factors associated with the development of MTX-related myelosuppression and its disease severity. Methods We retrospectively examined a total of 40 cases of MTX-related myelosuppression that had been filed in the registries of participating rheumatology and hematology divisions. Data before onset were compared with those of 120 controls matched for age and sex. Cytopenia was graded according to the National Cancer Institute criteria for adverse events. Data before and at onset were compared between the severe and non-severe groups. Results Non-use of folic acid supplements, concurrent medications, and low renal function were significantly associated with the development of myelosuppression (p < 0.001, p < 0.001, and p = 0.002, respectively). In addition, significantly lower MTX dosages, higher blood cell counts, and lower hemoglobin levels were seen in the myelosuppression group (p < 0.001). No patients exhibited leukocytopenia, neutropenia, or thrombocytopenia in routine blood monitoring taken within the past month. One-fourth developed myelosuppression within the first two months (an early-onset period). Myelosuppression was severe in approximately 40% of patients. Hypoalbuminemia and non-use of folic acid supplements were significantly associated with the severity of pancytopenia (p = 0.001 and 0.008, respectively). Besides these two factors, early onset and the use of lower doses of MTX were significantly associated with the severity of neutropenia (p = 0.003, 0.007, 0.003, and 0.002, respectively). Conclusions Myelosuppression can occur abruptly at any time during low-dose MTX therapy, but severe neutropenia is more likely to occur in the early-onset period of this therapy. Contrary to our expectations, disease severity was not dependent on MTX doses. Serum albumin levels and folic acid supplementation are the important factors affecting the severity of MTX-related pancytopenia and neutropenia.
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Nimmons D, Limdi JK. Elderly patients and inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016; 7:51-65. [PMID: 26855812 PMCID: PMC4734955 DOI: 10.4292/wjgpt.v7.i1.51] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/13/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is increasing globally. Coupled with an ageing population, the number of older patients with IBD is set to increase. The clinical features and therapeutic options in young and elderly patients are comparable but there are some significant differences. The wide differential diagnosis of IBD in elderly patients may result in a delay in diagnosis. The relative dearth of data specific to elderly IBD patients often resulting from their exclusion from pivotal clinical trials and the lack of consensus guidelines have made clinical decisions somewhat challenging. In addition, age specific concerns such as co-morbidity; loco-motor and cognitive function, poly-pharmacy and its consequences need to be taken into account. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this vulnerable group and set appropriate boundaries maximising benefit and minimising harm. Meanwhile, clinicians need to make personalised decisions but as evidence based as possible in the holistic, considered and optimal management of IBD in elderly patients. In this review we will cover the clinical features and therapeutic options of IBD in the elderly; as well as addressing common questions and challenges posed by its management.
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Romão VC, Lima A, Bernardes M, Canhão H, Fonseca JE. Three decades of low-dose methotrexate in rheumatoid arthritis: can we predict toxicity? Immunol Res 2015; 60:289-310. [PMID: 25391609 DOI: 10.1007/s12026-014-8564-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Methotrexate (MTX) is the anchor disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis (RA) treatment. It is used in monotherapy and/or in combination with other synthetic or biological DMARDs, and is known to have the best cost-effectiveness and efficacy/toxicity ratios. However, toxicity is still a concern, with a significant proportion of patients interrupting long-term treatment due to the occurrence of MTX-related adverse drug reactions (ADRs), which are the main cause of drug withdrawal. Despite the extensive accumulated experience in the last three decades, it is still impossible in routine clinical practice to identify patients prone to develop MTX toxicity. While clinical and biological variables, including folate supplementation, partially help to minimize MTX-related ADRs, the advent of pharmacogenomics could provide further insight into risk stratification and help to optimize drug monitoring and long-term retention. In this paper, we aimed to review and summarize current data on low-dose MTX-associated toxicity, its prevention and predictors, keeping in mind practical RA clinical care.
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Affiliation(s)
- Vasco C Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Edifício Egas Moniz, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
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Challenges in the Diagnosis and Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2015; 13:275-86. [DOI: 10.1007/s11938-015-0059-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Taleban S, Colombel JF, Mohler MJ, Fain MJ. Inflammatory bowel disease and the elderly: a review. J Crohns Colitis 2015; 9:507-15. [PMID: 25870198 DOI: 10.1093/ecco-jcc/jjv059] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/31/2015] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease among the elderly is common, with growing incident and prevalence rates. Compared with younger IBD patients, genetics contribute less to the pathogenesis of older-onset IBD, with dysbiosis and dysregulation of the immune system playing a more significant role. Diagnosis may be difficult in older individuals, as multiple other common diseases can mimic IBD in this population. The clinical manifestations in older-onset IBD are distinct, and patients tend to have less of a disease trajectory. Despite multiple effective medical and surgical treatment strategies for adults with Crohn's disease and ulcerative colitis, efficacy studies typically have excluded older subjects. A rapidly ageing population and increasing rates of Crohn's and ulcerative colitis make the paucity of data in older adults with IBD an increasingly important clinical issue.
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Affiliation(s)
- Sasha Taleban
- Department of Medicine, University of Arisona College of Medicine, Tucson, AZ, USA
| | | | - M Jane Mohler
- Department of Medicine, University of Arisona College of Medicine, Tucson, AZ, USA Arisona Center on Aging, University of Arisona, Tucson, AZ, USA
| | - Mindy J Fain
- Department of Medicine, University of Arisona College of Medicine, Tucson, AZ, USA Arisona Center on Aging, University of Arisona, Tucson, AZ, USA
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