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Wibrand C, Kyvsgaard N, Christensen AE, Herlin T. The role of liver transaminase levels in methotrexate intolerance in juvenile idiopathic arthritis-a cross-sectional study. Rheumatol Int 2023; 43:875-880. [PMID: 36922416 DOI: 10.1007/s00296-023-05297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/23/2023] [Indexed: 03/17/2023]
Abstract
Methotrexate (MTX) plays a key role when treating juvenile idiopathic arthritis (JIA), but MTX-intolerance is challenging. MTX-treatment might affect the liver, causing elevated levels of alanine aminotransferase (ALT), yet the role of ALT-levels in MTX-intolerance in JIA remains unclear. Our study aimed to investigate the association between ALT-levels during MTX-treatment and MTX-intolerance in JIA. Children (> 9 years old) diagnosed with JIA and treated with MTX (> 6 weeks) were eligible for enrollment. MTX-intolerance was assessed using the Methotrexate Intolerance Severity Score (MISS), completed by the parents, and defined as MISS ≥ 6 with at least 1 point for a behavioral/anticipatory/associative symptom. ALT-levels were determined at enrollment. A total of 118 children were enrolled (80 girls; 38 boys). MTX-intolerance was registered in 61%. ALT-levels did not differ between the MTX-intolerant group (median = 17.0 U/L [IQR: 14.0-26.0]) and the MTX-tolerant group (median = 20.5 U/L [IQR: 16.0-27.5]; p = 0.17). MTX-intolerance was prevalent in around 60% of both boys and girls. Nine out of 50 MTX-intolerant girls had elevated ALT-levels compared to 0/22 MTX-intolerant boys, however, there was no difference in median ALT levels between the two groups. Furthermore, the MTX-intolerant girls had a higher MISS (median = 14.0 [IQR: 9.3-17]) than the MTX-intolerant boys (median = 10.0 [IQR: 7.3-12]; p = 0.009). Our study did not find a difference in ALT-levels between MTX-intolerant and MTX-tolerant children. However, only MTX-intolerant girls and no MTX-intolerant boys showed elevated ALT-levels.
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Affiliation(s)
- Camilla Wibrand
- Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Nini Kyvsgaard
- Pediatric and Adolescent Medicine, Gødstrup Hospital, Gødstrup, Denmark
| | | | - Troels Herlin
- Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Smits RM, Veldhuijzen DS, van Middendorp H, Hissink Muller PCE, Armbrust W, Legger E, Wulffraat NM, Evers AWM. Pharmacological conditioning for juvenile idiopathic arthritis: a potential solution to reduce methotrexate intolerance. Pediatr Rheumatol Online J 2020; 18:12. [PMID: 32033577 PMCID: PMC7006148 DOI: 10.1186/s12969-020-0407-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/03/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Methotrexate (MTX) therapy has proven to be a successful and safe treatment for Juvenile Idiopathic Arthritis (JIA). Despite the high efficacy rates of MTX, treatment outcomes are often complicated by burdensome gastro-intestinal side effects. Intolerance rates for MTX in children are high (approximately 50%) and thus far no conclusive effective treatment strategies to control for side effects have been found. To address this need, this article proposes an innovative research approach based on pharmacological conditioning, to reduce MTX intolerance. PRESENTATION OF THE HYPOTHESIS A collaboration between medical psychologists, pediatric rheumatologists, pharmacologists and patient groups was set up to develop an innovative research design that may be implemented to study potential improved control of side effects in JIA, by making use of the psychobiological principles of pharmacological conditioning. In pharmacological conditioning designs, learned positive associations from drug therapies (conditioning effects) are integrated in regular treatment regimens to maximize treatment outcomes. Medication regimens with immunosuppressant drugs that made use of pharmacological conditioning principles have been shown to lead to optimized therapeutic effects with reduced drug dosing, which might ultimately cause a reduction in side effects. TESTING THE HYPOTHESIS This research design is tailored to serve the needs of the JIA patient group. We developed a research design in collaboration with an interdisciplinary research group consisting of patient representatives, pediatric rheumatologists, pharmacologists, and medical psychologists. IMPLICATIONS OF THE HYPOTHESIS Based on previous experimental and clinical findings of pharmacological conditioning with immune responses, we propose that the JIA patient group is particularly suited to benefit from a pharmacological conditioning design. Moreover, findings from this study may potentially also be promising for other patient groups that endure long-lasting drug therapies.
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Affiliation(s)
- Rosanne M. Smits
- 0000 0001 2312 1970grid.5132.5Health, Medical and Neuropsychology unit, Leiden University, Leiden, P.O. Box 9500, The Netherlands ,Leiden Institute for Brain and Cognition, Leiden, P.O. Box 9600, The Netherlands ,0000000090126352grid.7692.aDepartment Pediatric Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, P.O. Box 85090, The Netherlands
| | - Dieuwke S. Veldhuijzen
- 0000 0001 2312 1970grid.5132.5Health, Medical and Neuropsychology unit, Leiden University, Leiden, P.O. Box 9500, The Netherlands ,Leiden Institute for Brain and Cognition, Leiden, P.O. Box 9600, The Netherlands ,0000000090126352grid.7692.aDepartment Pediatric Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, P.O. Box 85090, The Netherlands
| | - Henriet van Middendorp
- 0000 0001 2312 1970grid.5132.5Health, Medical and Neuropsychology unit, Leiden University, Leiden, P.O. Box 9500, The Netherlands ,Leiden Institute for Brain and Cognition, Leiden, P.O. Box 9600, The Netherlands
| | - Petra C. E. Hissink Muller
- 0000000089452978grid.10419.3dDepartment Pediatric Rheumatology and Immunology, Leiden University Medical Center, Leiden, P.O. Box 9600, The Netherlands
| | - Wineke Armbrust
- 0000 0000 9558 4598grid.4494.dDepartment Pediatric Rheumatology and Immunology, University Medical Centre Groningen, Groningen, P.O. Box 30.001, The Netherlands
| | - Elizabeth Legger
- 0000 0000 9558 4598grid.4494.dDepartment Pediatric Rheumatology and Immunology, University Medical Centre Groningen, Groningen, P.O. Box 30.001, The Netherlands
| | - Nico M. Wulffraat
- 0000000090126352grid.7692.aDepartment Pediatric Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, P.O. Box 85090, The Netherlands
| | - Andrea W. M. Evers
- 0000 0001 2312 1970grid.5132.5Health, Medical and Neuropsychology unit, Leiden University, Leiden, P.O. Box 9500, The Netherlands ,Leiden Institute for Brain and Cognition, Leiden, P.O. Box 9600, The Netherlands ,0000000089452978grid.10419.3dDepartment of Psychiatry, Leiden University Medical Center, Leiden, P.O. Box 9600, The Netherlands
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Khan S, Mancini J, Hopper C, Rennick JE. Perceptions of Methotrexate Intolerance and Its Impact on Daily Life in School-Age Children with Juvenile Idiopathic Arthritis. J Pediatr Nurs 2019; 48:49-54. [PMID: 31254860 DOI: 10.1016/j.pedn.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Methotrexate (MTX) is a disease modifying anti-rheumatic drug commonly used to treat children with Juvenile Idiopathic Arthritis (JIA). Unfortunately, half of children taking MTX will experience MTX intolerance, which includes distressing gastrointestinal and behavioural symptoms associated with weekly MTX treatment. This qualitative study aimed to explore the perceptions of school-age children with JIA experiencing MTX intolerance, how they managed MTX intolerance, and how it impacted their daily life. DESIGN AND METHODS An interpretive descriptive design was used. Twelve children participated in one individual 30-minute semi-structured interview using a storyboard technique to elicit their perceptions through storytelling. Interview transcripts and observational data collected during the interviews were analyzed using inductive content analysis. RESULTS Children described MTX intolerance as extremely challenging. Three themes emerged from the data: (1) "No kid likes taking MTX". This theme was comprised of two subthemes related to: (a) associative MTX intolerance; namely, "Talking about it sometimes makes me feel sick"; and (b) anticipatory MTX intolerance, "Before [I take it], I have a little stomach ache". Other themes included: (2) The importance of strategies and routines; and (3) Working hard to live with MTX intolerance. CONCLUSIONS This study sheds new light on MTX intolerance as perceived by school-aged children with JIA. Results highlight the importance of providing families and healthcare professionals with the necessary information for early recognition of MTX intolerance and optimizing care through the development of early intervention strategies. PRACTICE IMPLICATIONS Study findings highlight the importance of prioritizing early identification and prevention of MTX intolerance.
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Affiliation(s)
- Sarah Khan
- Ingram School of Nursing, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Jacqueline Mancini
- Ingram School of Nursing, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Charlene Hopper
- The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Janet E Rennick
- Ingram School of Nursing, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
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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: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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