Prevalence and risk factors of methotrexate hepatoxicity in Asian patients with psoriasis

Psoriasis and steatotic liver disease: Are PNPLA3 and TM6SF2 polymorphisms suitable for the hepato-dermal axis hypothesis?

INTRODUCTION AND OBJECTIVES

A high prevalence of steatotic liver disease has been described in psoriasis. However, the influence of genetic polymorphisms has yet to be investigated in this scenario. This study aims to determine the frequency of steatosis, advanced liver fibrosis and PNPLA3/TM6SF2 genotypes in individuals with psoriasis and to evaluate the impact of genetic polymorphisms, metabolic parameters and cumulative methotrexate dose on steatosis and fibrosis.

MATERIALS AND METHODS

Cross-sectional study that prospectively included psoriasis outpatients, submitted to clinical and laboratory analysis, transient elastography (FibroScan®, Fr) and PNPLA3/TM6SF2 genotyping. Steatosis was defined by CAP ≥275 dB/m and advanced liver fibrosis as transient elastography ≥10 kPa. Logistic regression analysis evaluated the independent variables related to steatosis and fibrosis; p-value< 0.05 was considered significant.

RESULTS

One hundred and ninety-nine patients were enrolled (age 54.6 ± 12.6 years, 57.3% female). Metabolic syndrome (MetS), steatosis and advanced liver fibrosis prevalence were 55.8%, 54.8% and 9%, respectively. PNPLA3 and TM6SF2 genotypes frequencies were CC 42.3%/CG 49.5%/GG 8.2% and CC 88.7%/ CT 11.3%/ TT 0%. MetS (OR3.01 95%CI 1.51-5.98; p = 0.002) and body mass index (OR1.17 95%CI 1.08-1.26; p < 0.01) were independently associated with steatosis. Diabetes Mellitus (T2DM) (OR10.76 95%CI 2.42-47.87; p = 0.002) and harboring at least one PNPLA3 G allele (OR5.66 95%CI 1.08-29.52; p = 0.039) were associated with advanced fibrosis, but not TM6SF2 polymorphism or cumulative MTX dose.

CONCLUSIONS

MetS and T2DM confer higher odds for steatosis and advanced fibrosis in individuals with psoriasis. PNPLA3 G allele, but not TM6SF2 polymorphism, impacts a 5-fold odds of advanced liver fibrosis.

Nobiletin alleviates methotrexate-induced hepatorenal toxicity in rats

We investigated the possible ameliorative effects of nobiletin (NBL) against methotrexate (MTX)-induced hepatorenal toxicity in rats. Twenty-eight Wistar albino rats were randomly divided into four groups, namely: Control; MTX (administered 20 mg/kg MTX); MTX+NBL (administered 20 mg/kg MTX and 10 mg/kg NBL per day); and NBL (administered 10 mg/kg/day NBL). Histopathological, immunohistochemical and biochemical analyses were performed on the kidney and liver tissues of rats at the end of the study. MTX caused renal toxicity, as indicated by increases in malondialdehyde (MDA) and caspase-3, as well as decreases in reduced glutathione (GSH), glucose-6-phosphate dehydrogenase (G6PD), glutathione peroxidase (GPx), catalase (CAT) and B-cell lymphoma-2 (Bcl-2). MTX also caused hepatotoxicity, as indicated by increases in 8-hydroxy-2'-deoxyguanosine (8-OHdG), tumor necrosis factor alpha (TNF-α), MDA and caspase-3 and decrease in interleukin 10 (IL-10), GSH, total antioxidant capacity, GPx, G6PD, CAT and Bcl-2. MTX caused histopathological changes in kidney and liver tissues indicating tissue and cellular damage. Administration of NBL concurrently with methotrexate reduced oxidative stress, inflammatory and apoptotic signs, and prevented kidney and liver damage caused by methotrexate. We consider NBL has attenuating and ameliorating effects on methotrexate-induced hepatorenal toxicity.

Associated factors with liver fibrosis in rheumatoid arthritis patients treated with methotrexate

INTRODUCTION

There are conflicting findings on the link between liver fibrosis and cumulative methotrexate dosages. We aimed to determine the frequency of liver fibrosis in rheumatoid arthritis patients treated with methotrexate and to identify its associated factors.

METHODS

We conducted a cross-sectional study over 9 months (April-December 2021), including rheumatoid arthritis patients treated with methotrexate. Demographic and clinical data were collected. Liver stiffness was assessed by FibroScan. Fibrosis and significant liver fibrosis were defined as liver stiffness higher than 6 and 7.2 kPa, respectively. Liver tests, albuminemia, lipid profile, and blood glycemia were measured. Metabolic syndrome was also evaluated. Statistical analyses were performed using SPSS.

RESULTS

We included 21 men and 47 women. The mean age was 51.60 ± 1.82 years. The mean disease duration was 8.29 ± 6.48 years. The mean weekly intake of methotrexate was 13.76 ± 3.91 mg. The mean methotrexate duration was 4.67 ± 4.24 years. The mean cumulative dose was 3508.87 ± 3390.48 mg. Hypoalbuminemia and metabolic syndrome were found in 34% and 25% of cases. We noted increased alkaline phosphatase levels in four cases. The mean liver stiffness was 4.50 ± 1.53 kPa. Nine patients had liver fibrosis, and four had significant fibrosis. Associated factors with liver fibrosis were as follows: age ≥ 60 years (OR:22.703; 95%CI [1.238-416.487]; p = 0.035), cumulated dose of methotrexate ≥ 3 g (OR: 76.501; 95%CI [2.383-2456.070]; p = 0.014), metabolic syndrome (OR: 42.743; 95%CI [1.728-1057.273]; p = 0.022), elevated alkaline phosphatase levels (OR: 28.252; 95%CI [1.306-611.007]; p = 0.033), and hypoalbuminemia (OR: 59.302; 95%CI [2.361-1489.718]; p = 0.013).

CONCLUSION

Cumulating more than 3 g of methotrexate was associated with liver fibrosis in rheumatoid arthritis patients. Having a metabolic syndrome, higher age, hypoalbuminemia, and elevated alkaline phosphatase levels were also likely to be independently associated with liver fibrosis. Key points • Rheumatoid arthritis patients require monitoring hepatic fibrosis when the cumulated dose of methotrexate is above 3 g. • Metabolic syndrome is a risk factor for liver fibrosis, suggesting that its management is necessary to prevent this complication. • Hypoalbuminemia and elevated alkaline phosphatase levels (twice the upper limit) in rheumatoid arthritis patients treated with methotrexate were associated with liver fibrosis.

In-vivo anticancer efficacy of self-targeted methotrexate-loaded polymeric nanoparticles in solid tumor-bearing rat

Here, cytotoxicity and antitumor efficacy against a chemically (N-methyl-N-nitrosourea) generated mammary tumor in rats were assessed using methotrexate-loaded chitosan nanoparticles (Meth-Cs-NPs). Meth-Cs-NPs intravenous administrated resulted in noticeably decreased tumor incidence, multiplicity, and weight. Further, kidney function tests for the treated groups resulted in noticeably decreased ALP (Meth-Cs-NPs; 244 ± 15, diseases control; 403 ± 14 U/L), Creatinine (Meth-Cs-NPs; 0.81 ± 0.05, diseases control; 2 ± 0.05 mg/dl), and Urea (Meth-Cs-NPs; 56.62 ± 5, diseases control; 113 ± 6 mg/dl) levels, close to a normal control group. Similarly, liver function tests showed significantly decreased serum biomarkers, SGPT (Meth-Cs-NPs; 40 ± 1.8, diseases control; 84 ± 1.9 U/L) and SGOT (Meth-Cs-NPs; 15 ± 2, diseases control; 55 ± 4 U/L) levels in treated groups as compared to the untreated group (diseases control). From the results, pro-inflammatory cytokines were also markedly reduced in the treated group such as, TNF-α (Meth-Cs-NPs; 17.31 ± 1.15, diseases control; 36.9 ± 5 pg/mL), IL-1β (Meth-Cs-NPs; 433.3 ± 66.5, diseases control; 1540 ± 131.1 pg/mL), and IL-6 (Meth-Cs-NPs; 1515 ± 53, diseases control; 2200.6 ± 69 pg/mL) levels. Whereas Meth-Cs-NPs not only helped in lowering tumor multiplicity rates but also decrease inflammation. The studies could be successfully performed in chemically induced mammary tumors due to their easy, quick tumor growth and low mortality rates in rat models. According to the current study, Meth-Cs-NPs have high treatment potency and represent a possible therapeutic alternative for breast cancer treatment.

Combination Therapy for Psoriasis with Methotrexate and Other Oral Disease-Modifying Antirheumatic Drugs: A Systematic Review

INTRODUCTION

Although the introduction of biologics and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) has reshaped the treatment paradigm for immune-mediated inflammatory diseases (IMIDs) such as psoriasis, oral conventional synthetic DMARDs (csDMARDs) remain the cornerstone in their treatment. Combinational use of DMARDs is common in rheumatological practice, but for the treatment of many skin diseases, dermatologists typically use a single oral DMARD, with methotrexate (MTX) being the most commonly prescribed csDMARD for psoriasis.

METHODS

To better understand the potential benefits of MTX combination therapy in psoriasis, a literature review was conducted using Medline (PubMed), Embase, Web of Science, and the Cochrane Library, covering articles published from inception until October 2022. Randomized controlled trials, cohort, open-label, and observational studies, and case reports with efficacy and safety results for combination therapy with MTX, csDMARDs, and tsDMARDs or comparisons between MTX monotherapy and combination therapy with other oral DMARDs in psoriasis were included. Studies involving MTX monotherapy alone or sequential treatment with MTX and other oral DMARDs were excluded, as were non-English articles. The results are presented as a systematic review, and the risk of bias was assessed by the corresponding author using the Cochrane Handbook for Systematic Reviews of Interventions, version 6.3, and confirmed by an independent assessor.

RESULTS

Eleven studies comprising 494 participants were included in the review. Overall, combination treatment with MTX and other oral DMARDs exhibited good efficacy and tolerability in psoriasis. However, the included studies were primarily small scale or retrospective, and larger prospective randomized trials are needed to provide stronger evidence.

CONCLUSION

This literature review suggests that combination therapy with MTX and csDMARDs may serve as an efficacious treatment for psoriasis patients with an inadequate response to oral DMARD monotherapy.

Predicting Hepatotoxicity Associated with Low-Dose Methotrexate Using Machine Learning

An accurate prediction of the hepatotoxicity associated with low-dose methotrexate can provide evidence for a reasonable treatment choice. This study aimed to develop a machine learning-based prediction model to predict hepatotoxicity associated with low-dose methotrexate and explore the associated risk factors. Eligible patients with immune system disorders, who received low-dose methotrexate at West China Hospital between 1 January 2018, and 31 December 2019, were enrolled. A retrospective review of the included patients was conducted. Risk factors were selected from multiple patient characteristics, including demographics, admissions, and treatments. Eight algorithms, including eXtreme Gradient Boosting (XGBoost), AdaBoost, CatBoost, Gradient Boosting Decision Tree (GBDT), Light Gradient Boosting Machine (LightGBM), Tree-based Pipeline Optimization Tool (TPOT), Random Forest (RF), and Artificial Neural Network (ANN), were used to establish the prediction model. A total of 782 patients were included, and hepatotoxicity was detected in 35.68% (279/782) of the patients. The Random Forest model with the best predictive capacity was chosen to establish the prediction model (receiver operating characteristic curve 0.97, accuracy 64.33%, precision 50.00%, recall 32.14%, and F1 39.13%). Among the 15 risk factors, the highest score was a body mass index of 0.237, followed by age (0.198), the number of drugs (0.151), and the number of comorbidities (0.144). These factors demonstrated their importance in predicting hepatotoxicity associated with low-dose methotrexate. Using machine learning, this novel study established a predictive model for low-dose methotrexate-related hepatotoxicity. The model can improve medication safety in patients taking methotrexate in clinical practice.

Review of existing evidence demonstrates that methotrexate does not cause liver fibrosis

It has long been believed that methotrexate in therapeutic doses causes progressive liver injury resulting in advanced fibrosis and cirrhosis. Historically, this was a common indication for serial liver biopsy. However, new evidence suggests that methotrexate may not be a direct cause of liver injury; rather the injury and fibrosis attributed to methotrexate may be mediated by other mechanisms, specifically non-alcoholic fatty liver disease. The recent widespread use of non-invasive assessment of liver fibrosis has provided new evidence supporting this hypothesis. Thus, we conducted a meta-analysis and systematic review to determine whether methotrexate is indeed a direct cause of liver injury. For the meta-analysis portion, a comprehensive literature search was performed to identify manuscripts relevant to the topic. Of the 138 studies examined, 20 met our inclusion criteria. However, only 3 studies had sufficient homogeneity to allow aggregation. Thus, the remainder of the study was dedicated to a critical review of all studies relevant to the topic with particular attention to populations examined, risk factors, and assessment of injury and/or fibrosis. Meta-analysis did not show a statistically significant association between methotrexate dose and liver fibrosis. Individual studies reported fibrosis related to confounding factors such as diabetes, obesity, pre-existing chronic liver disease but not methotrexate exposure. In conclusion, existing evidence demonstrates that advanced liver fibrosis and cirrhosis previously attributed to methotrexate are in fact caused by metabolic liver disease or other chronic liver diseases, but not by methotrexate itself. This observation should direct the care of patients treated with long-term methotrexate.

Hepatotoxic potentials of methotrexate: Understanding the possible toxicological molecular mechanisms

Methotrexate (MTX) is one of the most effective and widely used drugs in the management of autoimmune and dermatological diseases. Rheumatoid arthritis and psoriasis patients who are under long term MTX-therapy are at high risk of developing a liver injury. Accumulation of intracellular MTX-polyglutamate (MTX-PG), a metabolite of MTX triggers oxidative stress, inflammation, steatosis, fibrosis, and apoptosis in hepatocytes. MTX-PG causes oxidative stress in the liver by inducing lipid peroxidation thereby releasing reactive oxygen species and suppressing antioxidant response elements. MTX-PG induces several pro-inflammatory signaling pathways and cytokines such as tumor necrosis factor-α, nuclear factor kappa B and interleukin 6 (IL-6), IL- β1, IL-12. MTX-PG depletes hepatic folate level and decreases RNA and DNA synthesis leading to hepatocyte death. MTX-PG inhibits 5-aminoimidazole-4-carboxamide ribonucleotide transformylase enzyme and thereby causes accumulation of intracellular adenosine, which causes activation of hepatic stellate cells, extracellular matrix accumulation and hepatic fibrosis. MTX-PG induces hepatocytes apoptosis by activation of caspase 3 via the intrinsic pathway. Clinically, aggravation of underlying fatty liver to non-alcoholic steatohepatitis with fibrosis seems to be an important mechanism of liver injury in MTX-treated RA patients. Therefore, there is a need for monitoring liver injury in RA, psoriatic and cancer patients with NAFLD and fibrosis risk factors during MTX treatment. This review summarizes the possible molecular mechanism of MTX-induced hepatotoxicity. It may pave the way for early detection of liver injury and develop novel strategies for treating MTX mediated hepatotoxicity.

Is methotrexate hepatotoxicity associated with cumulative dose? A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Methotrexate (MTX) is widely used in various medical specialties. However, hepatotoxicity is an ongoing concern and this is thought to be directly associated with cumulative dose. We sought to synthesise the published literature to evaluate the association between methotrexate hepatotoxicity and cumulative dose.

METHODS

A systematic review of Medline (PubMed) EMBASE, CINAHL and The Cochrane Library was performed. Full texts of articles were examined, and excluded articles were recorded with reasons for exclusion. A meta-analysis of correlation coefficients was performed using Fisher's z-transformation and a random effects model. Cochran's Q-test and the I² statistic were calculated to assess heterogeneity.

RESULTS

A total of 35 studies met inclusion criteria. Measures of hepatotoxicity were highly varied and included liver biopsy, elastography, FibroTest, biochemical tests and scoring systems (Fib-4, APRI, AST:ALT). Some studies analysed for the association with MTX cumulative dose using more than one modality. Overall, 38 analyses found no significant association between MTX cumulative dose and hepatoxicity vs eight that identified a significant association. The pooled correlation coefficient from five studies which utilised elastography was 0.18 (95% CI, -0.09 to 0.42), with significant heterogeneity between studies (P < 0.0001), I²  = 92%).

CONCLUSIONS

Our synthesis of a large volume of studies in this review found no significant association between MTX cumulative dose and hepatotoxicity, both in terms of vote counting and with regard to the meta-analysis of correlation coefficients from studies that utilised elastography. This challenges the long-held belief that liver injury is a direct result of drug accumulation.

The protective role of luteolin against the methotrexate-induced hepato-renal toxicity via its antioxidative, anti-inflammatory, and anti-apoptotic effects in rats

Methotrexate (MTX) is frequently used drug in treatment of cancer and autoimmune diseases. Unfortunately, MTX has many side effects including the hepato-renal toxicity. In this study, we hypothesized that Luteolin (Lut) exhibits protective effect against the MTX-induced hepato-renal toxicity. In order to investigate our hypothesis, the experiment was designed to examine the effect of exposure of male rats to MTX (20 mg/kg, i.p., at day 9) alone or together with Lut (50 mg/kg, oral for 14 days) compared to the control rats (received saline). The findings demonstrated that MTX treatment induced significant increases in the liver and kidney functions markers in serum samples including Aspartate transaminase (AST), Alanine transaminase (ALT), creatinine, urea and uric acid. MTX also mediated an oxidative stress expressed by elevated malondialdehyde (MDA) level and decreased level of reduced glutathione (GSH), antioxidant enzyme activities, and downregulation of the Nrf2 gene expression as an antioxidant trigger. Moreover, the inflammatory markers (NF-κB, TNF-α, and IL-1β) were significantly elevated upon MTX treatment. In addition, MTX showed an apoptotic response mediated by elevating the pro-apoptotic (Bax) and lowering the anti-apoptotic (Bcl-2) proteins. All of these changes were confirmed by the observed alterations in the histopathological examination of the hepatic and renal tissues. Lut exposure significantly reversed all the MTX-induced changes in the measured parameters suggesting its potential protective role against the MTX-induced toxicity. Finally, our findings concluded the antioxidative, anti-inflammatory and anti-apoptotic effects of Lut as a mechanism of its protective role against the MTX-induced hepato-renal toxicity in rats.

Effects of Rosmarinic Acid on Methotrexate-induced Nephrotoxicity and Hepatotoxicity in Wistar Rats

Introduction:

Methotrexate (MTX), used in the treatment of cancerous patients, causes toxicity in the different organs of the body. This study of rosmarinic acid (RA) is as an antioxidant on nephrotoxicity and hepatotoxicity induced by MTX.

Methods:

Rats (n = 32) were divided into four groups: sham; MTX; 100 mg\kg RA + MTX; 200 mg/kg RA + MTX. The amount of MTX was 20 mg/kg. 24 hours after injection of the last dose of MTX, the blood samples and kidneys and liver of rats were studied. The aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), urea, serum creatinine were assessed. Tissue antioxidant enzymes and malondialdehyde (MDA) levels were measured. The liver and kidney tissues were histopathologically examined.

Results:

MTX significantly increased the urea, creatinine, ALT, AST, ALP levels, and renal MDA and significantly decreased renal catalase (CAT), hepatic glutathione (GSH), and hepatic CAT activity. MTX induced necrosis, leukocyte infiltration, eosinophilic casts, glomerular damage in kidney tissue and necrosis, degeneration and cellular vacuolization in liver tissues. RA at 100 mg/kg caused a significant decrease in ALT and AST and at two doses significantly decreased urea, renal MDA, and liver MDA. RA at 200 mg/kg significantly increased the renal CAT and liver GSH. RA in two doses significantly decreased necrosis and Leukocyte infiltration. RA caused a significant decrease in degeneration and cellular vacuolization in liver tissues.

Conclusions:

RA with its antioxidant and anti-inflammatory characteristics decreased the MTX induced nephrotoxicity and hepatotoxicity.

Alleviation of Liver Dysfunction, Oxidative Stress and Inflammation Underlies the Protective Effect of Ferulic Acid in Methotrexate-Induced Hepatotoxicity

Introduction

In multiple studies, involvement of oxidative stress in the pathogenesis of methotrexate (MTX)-mediated liver damage has been confirmed. Use of many drugs has been examined experimentally in order to prevent or diminish oxidative stress. However, no study has yet examined the effects of ferulic acid (FA) on MTX-induced liver damage. This study aimed at evaluating the effects of FA on protection against liver damage induced by MTX in mice.

Materials and Methods

In this the mice were divided into five groups in a random manner: I) control; II) MTX (20 mg/kg); III and IV) FA (50 and 100 mg/kg) + MTX; and V) FA (100 mg/kg), and we measured serum factors, oxidative stress and inflammatory factors.

Results

In the MTX group, accumulation of inflammatory cells, accumulation of red blood cell (RBC), and nuclear pyknosis (NP) were detected in the liver. In line with the histological data, the levels of nitric oxide (NO), malondialdehyde (MDA), interleukin-6 (IL-6), and tumor necrosis factor-α increased (TNF-α), whereas the reduced glutathione (GSH), catalase (CAT), total antioxidant capacity (TAC), superoxide dismutase (SOD), and glutathione peroxidase (GPx) content reduced in the MTX group. However, FA ameliorated these hazardous effects in the antioxidant and anti-inflammatory systems in MTX-treated groups.

Conclusion

Based on our findings, oxidative stress impairment and MTX-induced liver damage were ameliorated following FA pretreatment at both histological and biochemical levels. Therefore, FA can be effectively used in abrogation of MTX-induced toxicity.

Psoriasis in Skin of Color: Insights into the Epidemiology, Clinical Presentation, Genetics, Quality-of-Life Impact, and Treatment of Psoriasis in Non-White Racial/Ethnic Groups

Psoriasis is a chronic inflammatory skin condition affecting diverse racial/ethnic groups throughout the world. Large population-based studies suggest that psoriasis occurs most often in individuals of European ancestry, followed by black and Hispanic individuals, although the true prevalence of psoriasis in non-white individuals is likely underestimated. Despite similarities in psoriasis between ethnic groups, there are notable differences in the presentation, quality-of-life impact, and treatment of psoriasis with important implications for the management of non-white individuals. Overall, heterogeneity in psoriasis susceptibility alleles, in combination with cultural and socioeconomic factors, may explain these differences. In this article, we review the epidemiology, clinical presentation, genetic polymorphisms, quality-of-life impact, and treatment nuances of psoriasis in patients with skin of color.

Liver Illness and Psoriatic Patients

Psoriasis is a chronic inflammatory disease of the skin affecting approximately 2% of the world's population. Systemic treatments, including methotrexate and cyclosporin, are associated with potential hepatotoxicity, due to either direct liver damage or immunosuppression or both immunomediated and a direct liver injury; therefore, treatment of patients with psoriasis poses a therapeutic challenge. The aim of this minireview is to help clinicians in the management of psoriatic patients who develop signs of liver dysfunction. To find relevant articles, a comprehensive search was performed on PubMed, EMBASE, and Cochrane with appropriate combinations of the following keywords being considered: viral hepatitis, nonalcoholic fatty liver disease, psoriasis, hepatotoxicity, drug toxicity, cholestasis, and autoimmune liver diseases.

Drug-induced Liver Injury: The Hepatic Pathologist's Approach

The evaluation of liver biopsies in suspected drug-induced liver injury (DILI) can be complex. The biopsy may be approached systematically, by identification of histologic lesions and then identification of the overall pattern of injury. Potential DILI must be separated from concomitant non-DILI liver disease. The findings can be analyzed with respect to the various prescription and nonprescription medications and dietary supplements under suspicion to provide a complete interpretation of the findings. The pathologic findings, the histologic differential diagnosis, and expert interpretation are part of a complete biopsy assessment and provide information that is of greatest value in patient management.

Role of nonalcoholic fatty liver disease as risk factor for drug-induced hepatotoxicity

BACKGROUND

Obesity is often associated with nonalcoholic fatty liver disease (NAFLD), which refers to a large spectrum of hepatic lesions including fatty liver, nonalcoholic steatohepatitis (NASH) and cirrhosis. Different investigations showed or suggested that obesity and NAFLD are able to increase the risk of hepatotoxicity of different drugs. Some of these drugs could induce more frequently an acute hepatitis in obese individuals whereas others could worsen pre-existing NAFLD.

AIM

The main objective of the present review was to collect the available information regarding the role of NAFLD as risk factor for drug-induced hepatotoxicity. For this purpose, we performed a data-mining analysis using different queries including drug-induced liver injury (or DILI), drug-induced hepatotoxicity, fatty liver, nonalcoholic fatty liver disease (or NAFLD), steatosis and obesity. The main data from the collected articles are reported in this review and when available, some pathophysiological hypotheses are put forward.

RELEVANCE FOR PATIENTS

Drugs that could pose a potential risk in obese patients include compounds belonging to different pharmacological classes such as acetaminophen, halothane, methotrexate, rosiglitazone, stavudine and tamoxifen. For some of these drugs, experimental investigations in obese rodents confirmed the clinical observations and unveiled different pathophysiological mechanisms which could explain why these pharmaceuticals are particularly hepatotoxic in obesity and NAFLD. Other drugs such as pentoxifylline, phenobarbital and omeprazole might also pose a risk but more investigations are required to determine whether this risk is significant or not. Because obese people often take several drugs for the treatment of different obesity-related diseases such as type 2 diabetes, hyperlipidemia and coronary heart disease, it is urgent to identify the main pharmaceuticals that can cause acute hepatitis on a fatty liver background or induce NAFLD worsening.

Assessment of Substantial Liver Fibrosis by Real-time Shear Wave Elastography in Methotrexate-Treated Patients With Rheumatoid Arthritis

OBJECTIVES

A concern about methotrexate (MTX)-related liver fibrosis in patients with rheumatoid arthritis (RA) is still unresolved. This study investigated the correlation between liver stiffness and the cumulative MTX dose and the risk factors associated with substantial liver fibrosis assessed by real-time shear wave elastography (SWE), a recently introduced technique to evaluate liver stiffness in patients with RA.

METHODS

Data from 185 patients with RA were prospectively collected. Patients were divided into 3 groups according to cumulative MTX dose (group 1, total dose <1500 mg; group 2, 1500-4000 mg, and group 3, >4000 mg) and compared with healthy control participants. A Pearson correlation analysis was performed to evaluate correlations between liver stiffness and other clinical and laboratory variables. Substantial liver fibrosis was defined as liver stiffness of greater than 8.6 kPa by SWE. Associated factors were tested in a multivariate logistic analysis.

RESULTS

The mean liver stiffness value in healthy controls was significantly lower than in patients with RA treated with MTX (P< .006), but there was no significant difference among the MTX groups. Liver stiffness and the cumulative MTX dose was not correlated. Substantial liver fibrosis was detected only in 9 patients (4.9%). Multivariate analysis adjusted by age and sex revealed that only a high body mass index (odds ratio, 1.79; 95% confidence interval, 1.34-2.39; P < .001) was associated with liver stiffness of greater than 8.6 kPa.

CONCLUSIONS

Substantial liver fibrosis on SWE was observed in about 5% of MTX-treated patients with RA and was associated with only a high body mass index but not with the cumulative MTX dose, suggesting that other comorbidities might have a more important role in liver fibrosis.

Mechanisms of Thymoquinone Hepatorenal Protection in Methotrexate-Induced Toxicity in Rats

To investigate mechanisms by which thymoquinone (TQ) can prevent methotrexate- (MTX-) induced hepatorenal toxicity, TQ (10 mg/kg) was administered orally for 10 days. In independent rat groups, MTX hepatorenal toxicity was induced via 20 mg/kg i.p. at the end of day 3 of experiment, with or without TQ. MTX caused deterioration in kidney and liver function, namely, blood urea nitrogen, creatinine, alanine aminotransferase, and aspartate aminotransferase. MTX also caused distortion in renal and hepatic histology, with significant oxidative stress, manifested by decrease in reduced glutathione and catalase, as well as increase in malondialdehyde levels. In addition, MTX caused nitrosative stress manifested by increased nitric oxide, with upregulation of inducible nitric oxide synthase. Furthermore, MTX caused hepatorenal inflammatory effects as shown by increased tumor necrosis factor-α, besides upregulation of necrosis factor-κB and cyclooxygenase-2 expressions. MTX also caused apoptotic effect, as it upregulated caspase 3 in liver and kidney. Using TQ concurrently with MTX restored kidney and liver functions, as well as their normal histology. TQ also reversed oxidative and nitrosative stress, as well as inflammatory and apoptotic signs caused by MTX alone. Thus, TQ may be beneficial adjuvant that confers hepatorenal protection to MTX toxicity via antioxidant, antinitrosative, anti-inflammatory, and antiapoptotic mechanisms.

Ciclamilast ameliorates adjuvant-induced arthritis in a rat model

We assessed the effect of a novel and selective phosphodiesterase 4 (PDE4) inhibitor, ciclamilast, on chronic inflammation in adjuvant-induced arthritis (AIA), a rat model of rheumatoid arthritis (RA), and acute inflammation in the rat and mouse model of carrageenan-induced paw edema and peritonitis. Our results showed that daily oral administration of ciclamilast at 1, 3, and 10 mg/kg dose-dependently inhibited the increase in hind paw volume of rats with AIA. The inhibition of paw edema was associated with inhibition of both the production of cytokines such as TNF-α, IL-1β, and IL-6 and cell infiltration assessed in subcutaneous paw tissue. Moreover, there was significantly less tissue destruction in the ciclamilast-treated rats compared to the vehicle-treated rats, as assessed by radiographic analysis and histopathological evaluation. In the two acute inflammation models, ciclamilast inhibited carrageenan-induced paw edema in rats and inflammatory cell migration into the peritoneal cavity in mice in a dose-dependent manner. These results not only suggest that ciclamilast, as a disease-modifying antirheumatic drug (DMARD), can attenuate RA but also provide proof of principle that a PDE4 inhibitor may be useful for the treatment of arthritis.