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Stewart S, Dodero-Anillo JM, Guijarro-Eguinoa J, Arias P, Gómez López De Las Huertas A, Seco-Meseguer E, García-García I, Ramírez García E, Rodríguez-Antolín C, Carcas AJ, Rodriguez-Novoa S, Rosas-Alonso R, Borobia AM. Advancing pharmacogenetic testing in a tertiary hospital: a retrospective analysis after 10 years of activity. Front Pharmacol 2023; 14:1292416. [PMID: 37927587 PMCID: PMC10622662 DOI: 10.3389/fphar.2023.1292416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
The field of pharmacogenetics (PGx) holds great promise in advancing personalized medicine by adapting treatments based on individual genetic profiles. Despite its benefits, there are still economic, ethical and institutional barriers that hinder its implementation in our healthcare environment. A retrospective analysis approach of anonymized data sourced from electronic health records was performed, encompassing a diverse patient population and evaluating key parameters such as prescribing patterns and test results, to assess the impact of pharmacogenetic testing. A head-to-head comparison with previously published activity results within the same pharmacogenetic laboratory was also conducted to contrast the progress made after 10 years. The analysis revealed significant utilization of pharmacogenetic testing in daily clinical practice, with 1,145 pharmacogenetic tests performed over a 1-year period and showing a 35% growth rate increase over time. Of the 17 different medical departments that sought PGx tests, the Oncology department accounted for the highest number, representing 58.47% of all genotyped patients. A total of 1,000 PGx tests were requested for individuals susceptible to receive a dose modification based on genotype, and 76 individuals received a genotype-guided dose adjustment. This study presents a comprehensive descriptive analysis of real-world data obtained from a public tertiary hospital laboratory specialized in pharmacogenetic testing, and presents data that strongly endorse the integration of pharmacogenetic testing into everyday clinical practice.
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Affiliation(s)
- Stefan Stewart
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital, Madrid, Spain
| | | | | | - Pedro Arias
- Pharmacogenetics Laboratory, Genetics Department, La Paz University Hospital, Madrid, Spain
| | | | | | - Irene García-García
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital, Madrid, Spain
| | - Elena Ramírez García
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital, Madrid, Spain
- Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carlos Rodríguez-Antolín
- Experimental Therapies and Novel Biomarkers in Cancer, Hospital La Paz Institute for Health Research—IdiPAZ, Madrid, Spain
| | - Antonio J. Carcas
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital, Madrid, Spain
- Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sonia Rodriguez-Novoa
- Genetics of Metabolic Diseases Laboratory, Genetics Department, La Paz University Hospital, Madrid, Spain
| | - Rocio Rosas-Alonso
- Pharmacogenetics Laboratory, Genetics Department, La Paz University Hospital, Madrid, Spain
- Experimental Therapies and Novel Biomarkers in Cancer, Hospital La Paz Institute for Health Research—IdiPAZ, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital, Madrid, Spain
- Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Kyvsgaard N, Mikkelsen TS, Als TD, Christensen AE, Corydon TJ, Herlin T. Single nucleotide polymorphisms associated with methotrexate-induced nausea in juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2021; 19:51. [PMID: 33794950 PMCID: PMC8017639 DOI: 10.1186/s12969-021-00539-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 03/23/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Context: Methotrexate (MTX) is a cornerstone in the treatment of juvenile idiopathic arthritis (JIA). MTX treatment is commonly associated with nausea. Large inter-individual variation exists in the level of MTX-induced nausea, possibly due to genetic factors. PURPOSE To investigate whether MTX-induced nausea was associated with single nucleotide polymorphisms (SNPs) in genes encoding MTX-transporter proteins, a MTX metabolizing enzyme and a nausea receptor. FINDINGS Methods: Children aged ≥9 years treated with MTX for JIA were eligible. MTX-induced nausea was registered by the children's completion of a nausea diary (min. 7 days) and the parents' completion of the MTX intolerance severity score (MISS). The selected SNPs were: SLCO1B1 (rs4149056; rs4149081), SLCO1B3 (rs2117032), SLC19A1 (rs1051266), ABCC2 (rs2273697; rs3740066; rs717620), ABCB1 (rs2032582; rs1045642), MTHFR (rs1801131, rs1801133), HTR3A (rs1062613; rs1985242; rs1176713) and HTR3B (rs1176744). RESULT Enrolled were 121 JIA patients (82 girls: 39 boys) with a median age of 13.3 years (IQR: 11.3-15.1). The median MTX dose was 9.7 mg/m2/week (IQR: 9.0-10.9). The median MTX treatment duration prior to enrolment was 340 days (IQR: 142-766). The SNP analysis was available for 119 patients. MTX intolerance was associated with the genotype distribution of rs1801133 (MTHFR) (p = 0.02). There was no additive effect of the minor alleles for any of the selected SNPs, nor any significant haplotype associations. CONCLUSION Summary: MTX-induced nausea may be influenced by genetic polymorphisms in a MTX metabolizing enzyme (rs1801133; MTHFR). IMPLICATIONS Further analyses involving inclusion of larger cohorts are needed to understand the impact of SNPs on MTX-induced nausea in JIA.
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Affiliation(s)
- Nini Kyvsgaard
- Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Torben Stamm Mikkelsen
- grid.154185.c0000 0004 0512 597XPediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Thomas D. Als
- grid.7048.b0000 0001 1956 2722Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Anne Estmann Christensen
- grid.7143.10000 0004 0512 5013Department of Pediatric Rheumatology, H.C. Andersen’s Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - Thomas J. Corydon
- grid.7048.b0000 0001 1956 2722Department of Biomedicine, Aarhus University, Aarhus, Denmark ,grid.154185.c0000 0004 0512 597XDepartment of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Herlin
- grid.154185.c0000 0004 0512 597XPediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Chen Y, Zou K, Sun J, Yang Y, Liu G. Associations between gene polymorphisms and treatment outcomes of methotrexate in patients with juvenile idiopathic arthritis. Pharmacogenomics 2018; 19:529-538. [PMID: 29589488 DOI: 10.2217/pgs-2017-0208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: Performance of a meta-analysis with respect to the genetic predictors of methotrexate (MTX) treatment outcomes, efficacy and toxicity, in patients with juvenile idiopathic arthritis (JIA). Methods: Databases of OVID MEDLINE and OVID EMBASE were searched to collect the studies addressing correlations between gene polymorphisms and efficacy and/or toxicity in MTX-treated JIA patients. Pooled odds ratios (ORs) with 95% CIs were estimated in allelic, recessive and/or dominant models. Results: With regards to efficacy, the C677T (rs1801133) polymorphism in MTHFR was associated with nonresponse to MTX treatment in a recessive model (OR: 0.40; 95% CI: 0.19–0.84). For associations with toxicity, the MTHFR C677T (rs1801133) polymorphism was associated with presenting overall adverse events in an allelic model (OR: 1.54; 95% CI: 1.07–2.22) and a dominant model (OR: 1.70; 95% CI: 1.08–2.68). Conclusion: C677T (rs1801133) polymorphism in MTHFR predicts nonresponse and/or adverse effects of MTX treatment in JIA patients.
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Affiliation(s)
- Yuehong Chen
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Kun Zou
- Department of Medical Record & Statistics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science & Technology, Chengdu, PR China
| | - Jianhong Sun
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yuan Yang
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Gang Liu
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
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Roszkiewicz J, Smolewska E. In the Pursuit of Methotrexate Treatment Response Biomarker in Juvenile Idiopathic Arthritis-Are We Getting Closer to Personalised Medicine? Curr Rheumatol Rep 2017; 19:19. [PMID: 28361333 DOI: 10.1007/s11926-017-0646-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Methotrexate (MTX) is the most widely used disease-modifying antirheumatic drug (DMARD) in paediatric rheumatology and the mainstay in the therapy of juvenile idiopathic arthritis (JIA). Despite its common use, about 30% of children fail to respond to this medicine that results in potentially irreversible joint damage. RECENT FINDINGS No clinical biomarker that would predict the outcome of MTX therapy exists. Results of several studies focused on gene polymorphisms and outcome of this DMARD therapy have been published, but no reliable genetic marker useful to tailor the therapy has been discovered so far. The results of the first genome-wide association study in this field have recently revealed new genetic candidates from outside the metabolic pathway of MTX that may be associated with the efficacy of treatment. However promising, those outcomes need validation in independent prospective cohorts before we can claim that clinically useful biomarker predicting MTX treatment response is discovered.
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Affiliation(s)
- Justyna Roszkiewicz
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland
| | - Elzbieta Smolewska
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland.
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Zajc Avramovič M, Dolžan V, Toplak N, Accetto M, Lusa L, Avčin T. Relationship Between Polymorphisms in Methotrexate Pathway Genes and Outcome of Methotrexate Treatment in a Cohort of 119 Patients with Juvenile Idiopathic Arthritis. J Rheumatol 2017; 44:1216-1223. [PMID: 28572465 DOI: 10.3899/jrheum.160950] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify clinical and pharmacogenetic determinants of efficacy and toxicity of methotrexate (MTX) in juvenile idiopathic arthritis (JIA) over time. METHODS A cohort of 119 consecutive patients with JIA treated with MTX was reviewed. The Juvenile Arthritis Disease Activity Score including 71 joints was used to measure disease activity. Nonresponders were patients who did not reach a minimum of 30% improvement after 6 months of treatment or were switched to biologic drugs in the first 6 months because of inefficacy. All adverse events (AE) were noted. Genotyping of single-nucleotide polymorphisms (SNP) in the genes coding for MTX transporters, folate pathway, and adenosine pathway was performed using real-time PCR methods. Univariate and multivariable penalized logistic and Cox regression were used to analyze data. RESULTS Thirty patients (25.8%) were defined as nonresponders and 55 (47.2%) were switched to biologics during the followup. Sixty-five patients (54.5%) reported AE in a total of 405 patient-years, and 10 patients (8.4%) discontinued MTX because of AE. AMPD1 rs17602729 and MTHFD1 rs2236225 were associated with gastrointestinal AE while the latter together with MTRR rs1801394 also demonstrated associations with developing hepatoxicity. MTHFR rs1801131, ABCG2 rs2231137, wild-type of MTR rs1805087, and wild-type of ABCC2 rs2273697 were identified as potential markers for discontinuing MTX treatment because of AE. MTHFR rs1801133, MTRR rs1801394, and ABCC2 rs2273697 were associated with switching to biologics. CONCLUSION SNP in different MTX metabolic pathways influence treatment with MTX. Genetic variability is a better marker for toxicity than efficacy.
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Affiliation(s)
- Mojca Zajc Avramovič
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Vita Dolžan
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Nataša Toplak
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Meta Accetto
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Lara Lusa
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Tadej Avčin
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia. .,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana.
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Kutuk MS, Subasioglu A, Uludag S, Tascioglu N, Ozgun MT, Dundar M. The effect of parental 5,10-methylenetetrahydrofolate reductase 677C/T and 1298A/C gene polymorphisms on response to single-dose methotrexate in tubal ectopic pregnancy. J Matern Fetal Neonatal Med 2016; 30:1232-1237. [PMID: 27379466 DOI: 10.1080/14767058.2016.1209652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECT The aim of this study was to assess the effect of parental 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms (677C/T and 1298A/C) on response to single-dose methotrexate (MTX) treatment in tubal ectopic pregnancy (TEP). MATERIALS AND METHODS In this prospective cohort study, cases with unruptured TEPs were grouped into two according to their response to single-dose MTX treatment (Group 1: responsive, n:88; Group 2: unresponsive, n:21). The groups were compared with regard to baseline demographic and clinical parameters. As a main outcome measure, the independent effects of parental MTHFR gene polymorphisms on response to single dose MTX treatment were evaluated. RESULTS One hundred and nine unruptured TEP were included in the final analysis. The mean maternal age was 29.30 ± 5.21 years, gravity 2 (min-max: 1-5), parity 1 (min-max: 0-4). The median serum beta-human chorionic gonadotropin (β-hCG) was 1403.35 MI/I (Q1-Q3: 517-2564). The overall response rate was 81% (88/109). The groups were similar with respect to basic baseline demographic data and serum β-hCG level. Binary logistic regression analysis showed that the presence of parental MTHFR677C/T and 1298A/C polymorphism were not independent factor predicting treatment success (p > 0.05). The only independent factor for resistance to single dose MTX was the previous TEP (OR: 4.47 (1.18-16.9)). CONCLUSION Parental MTHFR 677C/T and 1298A/C mutations do not predict the outcome of single dose intramuscular MTX treatment in unruptured TEP.
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Affiliation(s)
- Mehmet Serdar Kutuk
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Asli Subasioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Semih Uludag
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Nazife Tascioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Mahmut Tuncay Ozgun
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Munis Dundar
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
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Fráňová J, Fingerhutová Š, Kobrová K, Srp R, Němcová D, Hoza J, Uher M, Saifridová M, Linková L, Doležalová P. Methotrexate efficacy, but not its intolerance, is associated with the dose and route of administration. Pediatr Rheumatol Online J 2016; 14:36. [PMID: 27301536 PMCID: PMC4908704 DOI: 10.1186/s12969-016-0099-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/10/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is a lack of published evidence on the importance of methotrexate (MTX) dose and route of administration on both its efficacy and adverse events in children with Juvenile Idiopathic Arthritis (JIA). We aimed to document our clinical practice based on the treat-to-target approach in order to support the concept that better therapeutic effect achieved with an optimal dose of parenteral MTX is associated with clinically acceptable adverse effects comparable to those reported for oral treatment. METHODS Study inclusion criteria were indication of new MTX therapy for active arthritis in confirmed JIA patients younger than 18 years. Eligible patients were evaluated prospectively every 3 months for 1 year using standardized instruments for treatment response (American College of Rheumatology Pediatric (ACRPedi) response, Juvenile Arthritis Disease Activity Score (JADAS) 71, Clinically Inactive Disease (CID)) and adverse events (laboratory monitoring, Methotrexate Intolerance Severity Score (MISS)). MTX responders had to achieve at least ACRPedi 70 response. MTX intolerance was defined by MISS ≥ 6. RESULTS In 45/55 patients (81.8 %) MTX was started as subcutaneous injection. The initial median weekly dose was 14.4 mg/m(2) in parenteral and 11.7 mg/m(2) in oral administration. MTX therapy was effective in the level of ACRpedi70 and CID in 50.9 % and 30.9 % of patients at month 6 and in 70.9 % and 56.4 % after 12 months of the treatment, respectively. MTX intolerance at 6 and 12 months was noted in 25.5 % and 30.6 %, respectively. Management of intolerance included change in the dose and/or route of administration, education and councelling. Adverse events led to MTX withdrawal in 5 patients (9 %) due to toxicity (n = 3) and intolerance (n = 2). We did not find any significant predictive factors for either MTX therapeutic response or intolerance. CONCLUSION Subcutaneous MTX weekly dose around 15 mg/m(2) is associated not only with a high response rate within the first 12 months of treatment, but also with a relatively low rate of significant adverse effects that would lead to the treatment termination. It allows early recognition of MTX non-responders and addition of biologic therapy. Sustainability of therapeutic effect and longer-term evolution of adverse events will be addressed by an ongoing extension of the study.
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Affiliation(s)
- J Fráňová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
- Paediatric Rheumatology Unit, Department of Paediatrics, Children´s Medical Center, Faculty of Medicine, Masaryk University Brno and Faculty Hospital Brno, Černopolní 9, Brno, Czech Republic
| | - Š Fingerhutová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - K Kobrová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - R Srp
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - D Němcová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - J Hoza
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - M Uher
- Institute of Biostatistics and Analyses at the Faculty of Medicine and the Faculty of Science of the Masaryk University, Brno, Czech Republic
| | - M Saifridová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - L Linková
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - P Doležalová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic.
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van Dijkhuizen EHP, Bulatović Ćalasan M, Pluijm SMF, de Rotte MCFJ, Vastert SJ, Kamphuis S, de Jonge R, Wulffraat NM. Prediction of methotrexate intolerance in juvenile idiopathic arthritis: a prospective, observational cohort study. Pediatr Rheumatol Online J 2015; 13:5. [PMID: 25745368 PMCID: PMC4349799 DOI: 10.1186/s12969-015-0002-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methotrexate (MTX) is an effective and safe drug in the treatment of juvenile idiopathic arthritis (JIA). Despite its safety, MTX-related gastrointestinal adverse effects before and after MTX administration, termed MTX intolerance, occur frequently, leading to non-compliance and potentially premature MTX termination. The aim of this study was to construct a risk model to predict MTX intolerance. METHODS In a prospective JIA cohort, clinical variables and single nucleotide polymorphisms were determined at MTX start. The Methotrexate Intolerance Severity Score was employed to measure MTX intolerance in the first year of treatment. MTX intolerance was most prevalent at 6 or 12 months after MTX start, which was defined as the outcome for the prediction model. The model was developed in 152 patients using multivariable logistic regression analysis and subsequently internally validated using bootstrapping. RESULTS The prediction model included the following predictors: JIA category, antinuclear antibody, parent/patient assessment of pain, Juvenile Arthritis Disease Activity Score-27, thrombocytes, alanine aminotransferase and creatinine. The model classified 77.5% of patients correctly, and 66.7% of patients after internal validation by bootstrapping. The lowest predicted risk of MTX intolerance was 18.9% and the highest predicted risk was 85.9%. The prediction model was transformed into a risk score (range 0-17). At a cut-off of ≥6, sensitivity was 82.0%, specificity 56.1%, positive predictive value was 58.7% and negative predictive value 80.4%. CONCLUSIONS This clinical prediction model showed moderate predictive power to detect MTX intolerance. To develop into a clinically usable tool, it should be validated in an independent cohort and updated with new predictors. Such an easy-to-use tool could then assist clinicians in identifying patients at risk to develop MTX intolerance, and in turn to monitor them closely and intervene timely in order to prevent the development of MTX intolerance. TRIAL REGISTRATION ISRCTN register, www.isrctn.com, ISRCTN13524271.
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Affiliation(s)
- Evert Hendrik Pieter van Dijkhuizen
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands ,Pediatria II, Reumatologia, IRCCS G. Gaslini, Largo Gaslini 5, 16147 Genova, Italy
| | - Maja Bulatović Ćalasan
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Saskia MF Pluijm
- Department of Paediatric Haemato-Oncology, Erasmus University Medical Centre Rotterdam, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Maurits CFJ de Rotte
- Department of Clinical Chemistry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sebastiaan J Vastert
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Erasmus University Medical Centre Rotterdam, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Nico M Wulffraat
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
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van Dijkhuizen EHP, Wulffraat NM. Prediction of methotrexate efficacy and adverse events in patients with juvenile idiopathic arthritis: a systematic literature review. Pediatr Rheumatol Online J 2014; 12:51. [PMID: 25525416 PMCID: PMC4269851 DOI: 10.1186/1546-0096-12-51] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Methotrexate (MTX) is the cornerstone disease-modifying anti-rheumatic drug in juvenile idiopathic arthritis (JIA). In JIA, it is important to start effective treatment early to avoid long-term sequelae, such as joint damage. To accomplish this goal, it is crucial to know beforehand who is going to respond well to MTX. In addition, MTX adverse effects such as MTX intolerance occur frequently, potentially hindering its efficacy. To avoid inefficacy of an otherwise effective drug, the physician should be timely aware of these adverse events. Consequently, to optimise treatment of JIA patients with MTX, predictors for efficacy and adverse events should be used in daily clinical practice. The aim of this study was to summarise the existing knowledge about such predictors. METHODS A systematic literature search was performed in PubMed, Embase and The Cochrane Library, and 1,331 articles were identified. These were selected based on their relevance to the topic and critically appraised according to pre-defined criteria. Predictors for MTX efficacy and adverse events were extracted from the literature and tabulated. RESULTS Twenty articles were selected. The overall quality of the studies was good. For MTX efficacy, candidate predictors were antinuclear antibody positivity, the childhood health assessment questionnaire score, the myeloid-related protein 8/14 level, long-chain MTX polyglutamates, bilateral wrist involvement and some single nucleotide polymorphisms (SNPs) in the adenosine triphosphate binding cassette and solute carrier transporter gene families. For MTX adverse events, potential predictors were alanine aminotransferase and thrombocyte level and two SNPs in the γ-glutamyl hydrolase and methylenetetrahydrofolate reductase genes. However, validation of most predictors in independent cohorts was still lacking. CONCLUSIONS Interesting candidate predictors were found, especially for MTX efficacy. However, most of these were not validated. This should be the goal of future efforts. A clinically relevant way to validate the predictors is by means of creating a clinical prediction model.
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Affiliation(s)
- EH Pieter van Dijkhuizen
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands ,Pediatria II, Reumatologia, IRCCS G. Gaslini, Largo Gaslini, 5, 16147 Genova, Italy
| | - Nico M Wulffraat
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
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Bulatović Ćalasan M, Wulffraat NM. Methotrexate in juvenile idiopathic arthritis: towards tailor-made treatment. Expert Rev Clin Immunol 2014; 10:843-54. [DOI: 10.1586/1744666x.2014.916617] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Zhu H, Deng FY, Mo XB, Qiu YH, Lei SF. Pharmacogenetics and pharmacogenomics for rheumatoid arthritis responsiveness to methotrexate treatment: the 2013 update. Pharmacogenomics 2014; 15:551-66. [DOI: 10.2217/pgs.14.25] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rheumatoid arthritis (RA) is a complex, systemic autoimmune disease characterized by chronic inflammation of multiple peripheral joints, which leads to serious destruction of cartilage and bone, progressive deformity and severe disability. Methotrexate (MTX) is one of the first-line drugs commonly used in RA therapy owing to its excellent long-term efficacy and cheapness. However, the efficacy and toxicity of MTX treatment have significant interpatient variability. Genetic factors contribute to this variability. In this review, we have summarized and updated the progress of RA response to MTX treatment since 2009 by focusing on the fields of pharmacogenetics and pharmacogenomics. Identification of genetic factors involved in MTX treatment response will increase the understanding of RA pathology and the development of new personalized treatments.
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Affiliation(s)
- Hong Zhu
- Center for Genetic Epidemiology & Genomics, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, PR China
| | - Fei-Yan Deng
- Center for Genetic Epidemiology & Genomics, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, PR China
| | - Xing-Bo Mo
- Center for Genetic Epidemiology & Genomics, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, PR China
| | - Ying-Hua Qiu
- Center for Genetic Epidemiology & Genomics, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, PR China
| | - Shu-Feng Lei
- Center for Genetic Epidemiology & Genomics, School of Public Health, Soochow University, Suzhou, Jiangsu 215123, PR China
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Ćalasan MB, den Boer E, de Rotte MCFJ, Vastert SJ, Kamphuis S, de Jonge R, Wulffraat NM. Methotrexate polyglutamates in erythrocytes are associated with lower disease activity in juvenile idiopathic arthritis patients. Ann Rheum Dis 2013; 74:402-7. [PMID: 24288013 DOI: 10.1136/annrheumdis-2013-203723] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine association of erythrocyte methotrexate polyglutamates (MTX-PG) with disease activity and adverse effects in a prospective juvenile idiopathic arthritis (JIA) cohort. METHODS One hundred and thirteen JIA patients were followed from MTX start until 12 months. Erythrocyte MTX-PGs with 1-5 glutamate residues were measured at 3 months with tandem mass spectrometry. The outcomes were Juvenile Arthritis Disease Activity Score (JADAS)-27 and adverse effects. To determine associations of MTX-PGs with JADAS-27 at 3 months and during 1 year of MTX treatment, linear regression and linear mixed-model analyses were used. To determine associations of MTX-PGs with adverse effects during 1 year of MTX treatment, logistic regression was used. Analyses were corrected for JADAS-27 at baseline and co-medication. RESULTS Median JADAS-27 decreased from 12.7 (IQR: 7.8-18.2) at baseline to 2.9 (IQR: 0.1-6.5) at 12 months. Higher concentrations of MTX-PG3 (β: -0.006, p=0.005), MTX-PG4 (β: -0.015, p=0.004), MTX-PG5 (β: -0.051, p=0.011) and MTX-PG3-5 (β: -0.004, p=0.003) were associated with lower disease activity at 3 months. Higher concentrations of MTX-PG3 (β: -0.005, p=0.028), MTX-PG4 (β: -0.014, p=0.014), MTX-PG5 (β: -0.049, p=0.023) and MTX-PG3-5 (β: -0.004, p=0.018) were associated with lower disease activity over 1 year. None of the MTX-PGs was associated with adverse effects. CONCLUSIONS In the first prospective study in JIA, long-chain MTX-PGs were associated with lower JADAS-27 at 3 months and during 1 year of MTX treatment. Erythrocyte MTX-PG could be a plausible candidate for therapeutic drug monitoring of MTX in JIA.
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Affiliation(s)
- Maja Bulatović Ćalasan
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Ethan den Boer
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maurits C F J de Rotte
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sebastiaan J Vastert
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Erasmus University Medical Centre Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico M Wulffraat
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Ćalasan MB, Thurlings RM, Wulffraat NM, Prakken BJ. Translational medicine from bedside to bench and back again: methotrexate revisited. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.13.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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de ROTTE MAURITSC, BULATOVIC MAJA, HEIJSTEK MARLOESW, JANSEN GERRIT, HEIL SANDRAG, van SCHAIK RONH, WULFFRAAT NICOM, de JONGE ROBERT. ABCB1andABCC3Gene Polymorphisms Are Associated with First-year Response to Methotrexate in Juvenile Idiopathic Arthritis. J Rheumatol 2012; 39:2032-40. [DOI: 10.3899/jrheum.111593] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective.Although methotrexate (MTX) is the most widely prescribed drug in juvenile idiopathic arthritis (JIA), 30% of patients fail to respond to it. To individualize treatment strategies, the genetic determinants of response to MTX should be identified.Methods.A cohort of 287 patients with JIA treated with MTX was studied longitudinally over the first year of treatment. MTX response was defined as the American College of Rheumatology pediatric 70 criteria (ACRped70). We genotyped 21 single-nucleotide polymorphisms in 13 genes related to MTX polyglutamylation and to cellular MTX uptake and efflux. Potential associations between ACRped70 and genotypes were analyzed in a multivariate model and corrected for these 3 covariates: disease duration prior to MTX treatment, physician’s global assessment of disease activity at baseline, and MTX dose at all study visits.Results.MTX response was more often achieved by patients variant for the adenosine triphosphate-binding cassette transporter B1 (ABCB1) gene polymorphism rs1045642 (OR 3.80, 95% CI 1.70−8.47, p = 0.001) and patients variant for theABCC3gene polymorphism rs4793665 (OR 3.10, 95% CI 1.49−6.41, p = 0.002) than by patients with other genotypes. Patients variant for the solute carrier 19A1 (SLC19A1) gene polymorphism rs1051266 were less likely to respond to MTX (OR 0.25, 95% CI 0.09−0.72, p = 0.011).Conclusion.ABCB1rs1045642,ABCC3rs4793665, andSLC19A1rs1051266 polymorphisms were associated with response to MTX in 287 patients with JIA studied longitudinally. Upon validation of our results in other JIA cohorts, these genetic determinants may help to individualize treatment strategies by predicting clinical response to MTX.
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Yang L, Hu X, Xu L. Impact of methylenetetrahydrofolate reductase (MTHFR) polymorphisms on methotrexate-induced toxicities in acute lymphoblastic leukemia: a meta-analysis. Tumour Biol 2012; 33:1445-54. [DOI: 10.1007/s13277-012-0395-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 03/29/2012] [Indexed: 11/25/2022] Open
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Stamp LK, Roberts RL. Effect of genetic polymorphisms in the folate pathway on methotrexate therapy in rheumatic diseases. Pharmacogenomics 2012; 12:1449-63. [PMID: 22008049 DOI: 10.2217/pgs.11.86] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Methotrexate (MTX) is the first-line treatment for rheumatoid arthritis and is frequently used in the management of other forms of inflammatory arthritis. It is currently challenging to predict which patients will achieve adequate disease control and which patients will develop adverse effects while taking MTX. As an analog of dihydrofolic acid, MTX enters cells through the reduced folate carrier-1 protein, and is polyglutamated. MTX polyglutamates inhibit key enzymes in the folate pathway to produce an anti-inflammatory effect. It has been suggested that genetic polymorphisms in the folate pathway may influence intracellular folate and MTX polyglutamates pools, and thus MTX response. However, studies to identify genetic predictors have yielded inconclusive results. Nonreplication across studies has been attributed to insufficient statistical power as well as pharmacological and clinical confounders. Prospective studies, standardizing the definitions of response and toxicity, and application of genome-wide approaches may advance the search for genetic predictors of MTX response.
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Affiliation(s)
- Lisa K Stamp
- Department of Biochemistry, University of Otago, Dunedin 9054, New Zealand.
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Abstract
Methotrexate (MTX) is a safe and well-tolerated drug for the treatment of rheumatic diseases, even if the strictest safety standards are considered. Initial apprehension as to severe pulmonary or hepatic side-effects has not been confirmed. The risk of infection is not elevated compared with other disease-modifying antirheumatic drugs. In addition, a mutagenic potential could not be demonstrated even after long-term application. Therefore, MTX will maintain its significant role in antirheumatic therapy also in the near future.
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Affiliation(s)
- G Keysser
- Department für Innere Medizin, Klinik für Innere Medizin II/Arbeitsbereich Rheumatologie, Universitätsklinik Halle (Saale), Halle (Saale), Germany.
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Quartier P. Current treatments for juvenile idiopathic arthritis. Joint Bone Spine 2010; 77:511-6. [DOI: 10.1016/j.jbspin.2010.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2010] [Indexed: 10/18/2022]
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