Is methotrexate safe for men with an immune-mediated inflammatory disease and an active desire to become a father? Results of a prospective cohort study (iFAME-MTX)

INTRODUCTION

Current scientific evidence guiding the decision whether men with an active desire to become a father should be treated with methotrexate (MTX) remains controversial. We aimed to prospectively evaluate the testicular toxicity profile of MTX focusing on several markers of male fertility, including semen parameters and sperm DNA fragmentation index (sDFI). As a secondary outcome, we aimed to evaluate whether MTX-polyglutamates can be detected in spermatozoa and seminal plasma and to evaluate the enzymatic activity in spermatozoa of folylpolyglutamate synthetase (FPGS).

METHODS

In a prospective cohort study, men ≥18 years who started therapy with MTX were invited to participate (MTX-starters). Participants were instructed to produce two semen samples (a pre-exposure and a post-exposure sample after 13 weeks). Healthy men ≥18 years were invited to participate as controls. Conventional semen analyses, male reproductive endocrine axis and sDFI were compared between groups. FPGS enzymatic activity and MTX-PG1-5 concentrations were determined by mass spectrometry analytical methods.

RESULTS

In total, 20 MTX-starters and 25 controls were included. The pre-exposure and postexposure semen parameters of MTX-starters were not statistically significant different. Compared with healthy controls, the conventional semen parameters and the sDFI of MTX-starters were not statistically significant different. These data were corroborated by the marginal accumulation of MTX-PGs in spermatozoa, consistent with the very low FPGS enzymatic activity associated with the expression of an alternative FPGS splice-variant.

DISCUSSION

Treatment with MTX is not associated with testicular toxicity, consistent with the very low concentration of intracellular MTX-PG. Therefore, therapy with MTX can be safely started or continued in men and with a wish to become a father.

Recurrence risk of venous thromboembolism associated with systemic lupus erythematosus: A retrospective cohort study

Background

Recurrence risk of systemic lupus erythematosus (SLE)-associated venous thromboembolism (VTE) is unclear.

Aim

To determine the recurrence risk of SLE-associated VTE overall and by presence of provoking factors and SLE flares.

Methods

A multicenter, retrospective cohort study was conducted among patients with first SLE-associated VTE who discontinued anticoagulation. SLE flares were defined as Systemic Lupus Erythematosus Disease Activity Index 2000 greater than 4. The primary outcome was recurrent VTE. Incidence rates and cumulative incidences were calculated by presence of provoking factors and antiphospholipid syndrome (APS) at index VTE. The hazard ratio (HR) for recurrence after SLE flare-associated index VTE was estimated with Cox regression, adjusted for provoking factor presence and APS.

Results

Eighty patients were included with 21 recurrent VTEs in median 8 years. For provoked index VTE, the recurrence rate in patients without APS was 1.1 per 100 person-years (PY; 95% confidence interval [CI], 0.1-3.1) and in the presence of APS 3.5 per 100 PY (95% CI, 0.9-8.9), yielding cumulative incidences of 7.5% (95% CI, 1.2%-21.7%) and 31.4% (95% CI, 6.3%-61.6%) respectively. For unprovoked index VTE, these analogous rates were 3.8 per 100 PY (95% CI, 1.2-9.0) and 16.7 per 100 PY (95% CI, 4.5-42.7), with cumulative incidences of 33.7% (95% CI, 10.7%-58.9%) and 54.2% (95% CI, 10.7%-84.5%), respectively. Forty-six index VTEs were flare associated, and the adjusted HR for recurrence was 0.4 (95% CI, 0.1-1.8) compared to those without flares at their index VTE.

Conclusion

Antiphospholipid syndrome is the main determinant for recurrence risk of SLE-associated VTE irrespective of presence of a provoking factor. Future research should attempt to confirm that flare-associated VTE has a lower recurrence risk.

OP0131 WHAT IS THE EFFECT OF METHOTREXATE ON SEMEN PARAMETERS OF MEN DIAGNOSED WITH IMMUNE-MEDIATED DISEASES? RESULTS OF A PROSPECTIVE COHORT STUDY (iFAME-MTX)

Background

Methotrexate (MTX) is one of the most frequently prescribed medications for the treatment of several immune-mediated diseases (IMD). MTX has well-established safety and efficacy profiles. Nonetheless, the available scientific evidence to support the decision whether men with an active desire to become a father should be treated with MTX is dubious (1). This knowledge gap is characterized by a lack of prospective studies evaluating the semen parameters before and after exposure to MTX (2).

Objectives

Our objective is to compare the semen parameters (sperm concentration, volume and progressive motility) between men diagnosed with IMD (pre and post exposure to MTX) and healthy controls.

Methods

This is a prospective cohort study. Men diagnosed with an IMD (RA, SpA, psoriasis) who were older than 18 years and received a medical indication to start therapy with MTX were invited to participate (naïve cases). These men were instructed to produce 2 semen samples (a pre-exposure sample before initiating MTX therapy and a post-exposure sample 12 weeks after initiating MTX therapy). Healthy men who were over 18 years old were invited to participate as healthy controls. Furthermore, to evaluate the semen parameters of men chronically exposed to MTX, men diagnosed with an IMD who had been exposed to MTX (≥15 mg/week) for at least 1 year were also invited to participate (chronic cases). These men produced one semen sample (post-exposure). All participants were proven fertile (fathered a child or their partner reported a positive pregnancy test). Continuous variables were compared using a paired t-test or a one-way analysis of variance.

Results

In total 18 naïve cases, 25 healthy controls and 5 chronic cases were included. Their demographic characteristics and the results of the conventional semen analysis are presented per group in Table 1. Compared to the semen parameters (sperm concentration, volume and progressive motility) from healthy controls, pre-exposure and post-exposure semen parameters from naïve cases were not statistically significant different (see Figure 1). The semen parameters of chronic cases were also not statistically significant different compared to pre-exposure samples from naïve cases and to healthy controls. Oligospermia (sperm concentration <15 10^6/mL) was identified in two samples from a naïve case (pre and post-exposure to MTX) and no cases of azoospermia were identified.

Table 1.

Demographic, clinical characteristics and semen parameters

MTX naïveControlsMTX chronicp valuePre-exposurePost-exposureTotal, n18255Age, mean (95% CI)36.52 (33.65-39.39)34.56(32.75-36.36)36.80(31.95 – 41.64)MTX dose mg/week, mean (95% CI)-16.52(14.54 – 18.49)-18.00(14.59 – 21.40)Sperm concentration, mean × 10^6/ mL (95% CI)84.27(44.27-123.83)64.31(42.55 – 86.35)92.56(60.45 –124.66)44.60(25.11 – 64.08)p=0.358*p=0.280**Progressive motility*, % (95% CI)63.20(55.44-70.95)60.11(49.56-70.67)56.95(51.05-62.85)50.40(34.82 – 65.97)p=0.562*p=0.456**Semen volume, mean mL,(95% CI)2.93(2.09-3.76)2.90(2.08-3.71)3.12(2.51-3.73)2.50(1.55-3.44)p=0.608*p=0.593**

*Comparisons between pre and post exposure samples were tested using a paired t-test,

**Comparisons between pre, post exposure and healthy controls were tested using a one way analysis of variance.

Conclusion

This is the largest prospective study ever conducted to evaluate the impact of MTX on semen parameters in men diagnosed with IMDs. We demonstrated that exposure to MTX did not result in statistically significant different semen parameters. Based on semen parameters, our findings suggest that MTX therapy can be continued in men diagnosed with an IMD and a wish to become a father.

References

[1]Sammaritano LR et al. Arthritis Care Res (Hoboken). 2020;72(4):461-88.

[2]Perez-Garcia LF et al. Human Reproduction Update. 2020.

Disclosure of Interests

None declared

Effects of Childhood-onset Systemic Lupus Erythematosus on Academic Achievements and Employment in Adult Life

OBJECTIVE

Long-term outcome data in adults with childhood-onset systemic lupus erythematosus (cSLE) are limited. Here, we report the effects of cSLE on education, vocation, and employment in a large cohort of adults with cSLE.

METHODS

Patients were seen for a single study visit comprising a structured history and physical examination. Medical records were retrieved to supplement information obtained during the study visit. Education and employment status were assessed by questionnaires. Health-related quality of life (HRQOL) was measured with the 36-Item Short Form Health Survey (SF-36).

RESULTS

One hundred six patients with cSLE (93% female, 73% White), with a median disease duration of 20 years, completed the visit and questionnaires. Almost all patients stated that cSLE had influenced their education, but the level of completed education was similar to the general Dutch population. Half of the patients had adjusted their vocational choice due to the disease. Still, 44% of patients who had finished education did not have a paid job. Of the employed patients, 61% worked part time. Disease damage was equally prevalent in patients with and without paid employment. A high percentage of patients (51%) were declared work disabled, due to disease damage. Patients who did not have paid employment were often work disabled. Both had a negative effect on HRQOL.

CONCLUSION

The effect of cSLE on academic achievements and employment is substantial, despite patients adjusting their educational and vocational choices. To optimize participation in the community, ongoing support is necessary, not only to help patients find suitable education and vocations but also to offer guidance regarding potential adjustments during their career.

Long-Term Clinical Outcomes in a Cohort of Adults With Childhood-Onset Systemic Lupus Erythematosus

Objective

Childhood‐onset systemic lupus erythematosus (SLE) is a severe, lifelong, multisystem autoimmune disease. Long‐term outcome data are limited. This study was undertaken to identify clinical characteristics and health‐related quality of life (HRQoL) of adults with childhood‐onset SLE.

Methods

Patients participated in a single study visit comprising a structured history and physical examination. Disease activity (scored using the SLE Disease Activity Index 2000 [SLEDAI‐2K]), damage (scored using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI]), and HRQoL (scored using the Short Form 36 Health Survey) were assessed. Medical records were reviewed.

Results

In total, 111 childhood‐onset SLE patients were included; the median disease duration was 20 years, 91% of patients were female, and 72% were white. Disease activity was low (median SLEDAI‐2K score 4), and 71% of patients received prednisone, hydroxychloroquine (HCQ), and/or other disease‐modifying antirheumatic drugs. The vast majority of new childhood‐onset SLE–related manifestations developed within 2 years of diagnosis. Damage such as myocardial infarctions began occurring after 5 years. Most patients (62%) experienced damage, predominantly in the musculoskeletal, neuropsychiatric, and renal systems. Cerebrovascular accidents, renal transplants, replacement arthroplasties, and myocardial infarctions typically occurred at a young age (median age 20 years, 24 years, 34 years, and 39 years, respectively). Multivariate logistic regression analysis showed that damage accrual was associated with disease duration (odds ratio [OR] 1.15, P < 0.001), antiphospholipid antibody positivity (OR 3.56, P = 0.026), and hypertension (OR 3.21, P = 0.043). Current HCQ monotherapy was associated with an SDI score of 0 (OR 0.16, P = 0.009). In this cohort, HRQoL was impaired compared to the overall Dutch population. The presence of damage reduced HRQoL scores in 1 domain. High disease activity (SLEDAI‐2K score ≥8) and changes in physical appearance strongly reduced HRQoL scores (in 4 of 8 domains and 7 of 8 domains, respectively).

Conclusion

The majority of adults with childhood‐onset SLE in this large cohort developed significant damage at a young age and had impaired HRQoL without achieving drug‐free remission, illustrating the substantial impact of childhood‐onset SLE on future life.