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Freeman ML, Clagett BM, Moisi D, Yeh E, Morris CD, Ryu A, Rodriguez B, Stein JH, Deeks SG, Currier JS, Hsue PY, Anthony DD, Calabrese LH, Ribaudo HJ, Lederman MM. Methotrexate Inhibits T Cell Proliferation but Not Inflammatory Cytokine Expression to Modulate Immunity in People Living With HIV. Front Immunol 2022; 13:924718. [PMID: 35967371 PMCID: PMC9374564 DOI: 10.3389/fimmu.2022.924718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Inflammation associated with increased risk of comorbidities persists in people living with HIV (PWH) on combination antiretroviral therapy (ART). A recent placebo-controlled trial of low-dose methotrexate (MTX) in PWH found that numbers of total CD4 and CD8 T cells decreased in the low-dose MTX arm. In this report we analyzed T cell phenotypes and additional plasma inflammatory indices in samples from the trial. We found that cycling (Ki67+) T cells lacking Bcl-2 were reduced by MTX but plasma inflammatory cytokines were largely unaffected. In a series of in vitro experiments to further investigate the mechanisms of MTX activity, we found that MTX did not inhibit effector cytokine production but inhibited T cell proliferation downstream of mTOR activation, mitochondrial function, and cell cycle entry. This inhibitory effect was reversible with folinic acid, suggesting low-dose MTX exerts anti-inflammatory effects in vivo in PWH largely by blocking T cell proliferation via dihydrofolate reductase inhibition, yet daily administration of folic acid did not rescue this effect in trial participants. Our findings identify the main mechanism of action of this widely used anti-inflammatory medicine in PWH and may provide insight into how MTX works in the setting of other inflammatory conditions.
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Affiliation(s)
- Michael L. Freeman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Brian M. Clagett
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Daniela Moisi
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Eunice Yeh
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Charles D. Morris
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Angela Ryu
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Benigno Rodriguez
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - James H. Stein
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Steven G. Deeks
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of San Francisco School of Medicine, San Francisco, CA, United States
| | - Judith S. Currier
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Priscilla Y. Hsue
- Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, United States
| | - Donald D. Anthony
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
- Louis Stokes Cleveland Veterans Affairs Medical Center, US Department of Veterans Affairs, Cleveland, OH, United States
- Division of Rheumatic Diseases, MetroHealth Medical Center, Cleveland, OH, United States
| | - Leonard H. Calabrese
- Fasenmyer Center for Immunology, Division of Rheumatic Diseases, Cleveland Clinic, Cleveland, OH, United States
| | - Heather J. Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Michael M. Lederman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
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Huang CY, Su YC, Lu CY, Chiu PL, Chang YM, Ju DT, Chen RJ, Yang LY, Ho TJ, Kao HC. Edible folic acid and medicinal folinic acid produce cardioprotective effects in late-stage triple-transgenic Alzheimer's disease model mice by suppressing cardiac hypertrophy and fibrosis. ENVIRONMENTAL TOXICOLOGY 2022; 37:1740-1749. [PMID: 35286012 DOI: 10.1002/tox.23521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 06/14/2023]
Abstract
Some clinical studies have indicated the patients with Alzheimer's disease (AD) display an increased risk of cardiovascular disease (CVD). Here, to examine the relationship between AD and CVDs, we investigated the changes in heart function in triple-transgenic late-stage AD model mice (3× Tg-AD; APPSwe, PS1M146V, and tauP301L). We fed the AD mice folic acid (FA) or folinic acid (FN) and analyzed the protective effects of the compounds on the heart; specifically, 20-month-old triple-transgenic AD mice, weighing 34-55 g, were randomly allocated into three groups-the AD, AD + FA, and AD + FN groups-and subject to gastric feeding with FA or FN once daily at 12 mg/kg body weight (BW) for 3 months. Mouse BWs were assessed throughout the trial, at the end of which the animals were sacrificed using carbon dioxide suffocation. We found that BW, whole-heart weight, and left-ventricle weight were reduced in the AD + FA and AD + FN groups as compared with the measurements in the AD group. Furthermore, western blotting of excised heart tissue revealed that the levels of the hypertrophy-related protein markers phospho(p)-p38 and p-c-Jun were markedly decreased in the AD + FA group, whereas p-GATA4, and ANP were strongly reduced in the AD + FN group. Moreover, the fibrosis-related proteins uPA, MMP-2, MEK1/2 and SP-1 were decreased in the heart in both AD + FN group. In summary, our results indicate that FA and FN can exert anti-cardiac hypertrophy and fibrosis effects to protect the heart in aged triple-transgenic AD model mice, particular in FN.
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Affiliation(s)
- Chih-Yang Huang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Biotechnology, Asia University, Taichung, Taiwan
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Center of General Education, Buddhist Tzu Chi Medical Foundation, Tzu Chi University of Science and Technology, Hualien, Taiwan
| | - Yi-Chen Su
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
| | - Cheng-You Lu
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | | | | | - Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ray-Jade Chen
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Liang-Yo Yang
- Department of Physiology, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Laboratory for Neural Repair, China Medical University Hospital, Taichung, Taiwan
| | - Tsung-Jung Ho
- Integration Center of Traditional Chinese and Modern Medicine, HualienTzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
- School of Post-Baccalaure-ate Chinese Medicine, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hui-Chuan Kao
- Department of Public Health, Tzu Chi University, Hualien, Taiwan
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Efficacy of folinic acid rescue following MTX GVHD prophylaxis: results of a double-blind, randomized, controlled study. Blood Adv 2021; 4:3822-3828. [PMID: 32790844 DOI: 10.1182/bloodadvances.2020002039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/07/2020] [Indexed: 12/22/2022] Open
Abstract
The use of methotrexate (MTX) for graft-versus-host disease (GVHD) prophylaxis is associated with increased rates of organ-specific toxicities. Despite limited data, the European Society for Blood and Marrow Transplantation-European LeukemiaNet working group recommend the use of folinic acid (FA) rescue to reduce MTX toxicity after allogeneic hematopoietic cell transplantation (allo-HCT). In a multicenter, double-blind, randomized, controlled trial, we explored whether FA rescue reduces MTX-induced toxicity. We enrolled patients undergoing allo-HCT with myeloablative conditioning with peripheral blood stem cell grafts, with GVHD prophylaxis consisting of cyclosporine and MTX. Patients were randomized to receive FA or placebo starting 24 hours after each MTX dose and continuing over 24 hours in 3 to 4 divided doses. The primary end point was the rate of grades 3 and 4 oral mucositis. After enrollment of 52 patients (FA, n = 28; placebo, n = 24), preplanned interim analysis revealed similar rates of grade 3 and 4 (46.6% vs 45.8%; P = .97) and grades 1 to 4 (83.3% vs 77.8%; P = .65) oral mucositis. With a median follow-up of 17 (range, 4.5-50) months, there was no difference in the rates of acute and chronic GVHD, disease relapse, nonrelapse mortality, and overall survival. These interim results did not support continuation of the study. We conclude that FA rescue after MTX GVHD prophylaxis does not decrease regimen-related toxicity or affect transplantation outcomes. This study was registered at clinicaltrials.gov as #NCT02506231.
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Naushad SM, Alrokayan SA, Almajhdi FN, Hussain T. Influence of RFC1 c.80A>G Polymorphism on Methotrexate-Mediated Toxicity and Therapeutic Efficacy in Rheumatoid Arthritis: A Meta-analysis. Ann Pharmacother 2021; 55:1429-1438. [PMID: 33749319 DOI: 10.1177/10600280211002053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Methotrexate (MTX) is an antirheumatic drug, transported by reduced folate carrier-1 (RFC1). The most common RFC1 gene variant, c.80 A>G (rs1051266) is ambiguously linked to adverse effects of MTX therapy in some rheumatoid arthritis (RA) patients. OBJECTIVE The purpose of meta-analysis was to summarize all major published studies on c.80 A>G SNP to clarify this ambiguity in MTX therapy. METHODS A total of 18 studies representing 3592 RA patients comprising 699 men and 2893 women were included. Both fixed and random effect models were applied to study the data. RESULTS The RFC1 80A-allele showed null association with MTX-mediated toxicity in both fixed (odds ratio [OR] = 0.91; 95% CI = 0.80-1.03) and random effects (OR = 0.89; 95% CI: 0.71-1.11) models. Because heterogeneity was observed in this association (P = 0.0006), data were segregated based on use of folate therapy. In 7 studies (n = 1191) where folate was used along with MTX, RFC1 AA patients showed reduced risk for MTX-mediated toxicity (OR = 0.67; 95% CI: 0.50-0.89; P = 0.0006). The RFC1 80A-allele was found to increase the efficacy of MTX therapy by 1.53-fold (95% CI: 1.24-1.88), whereas the 80AA-genotype increased the efficacy by 1.85-fold (95% CI: 1.41-2.42). No publication bias was observed in these associations. CONCLUSION AND RELEVANCE RFC1 c.80 A>G is an important pharmacogenetic determinant of MTX therapy in RA. The RFC1 80A-allele robustly increased therapeutic efficacy and safety when folate was used along with MTX. Findings are relevant to decision-making in the clinical use of MTX as a treatment for RA patients harboring the RFC1 gene variant.
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Affiliation(s)
- Shaik Mohammad Naushad
- Biochemical Genetics and Pharmacogenomics, Sandor Specialty Diagnostics Pvt Ltd, Hyderabad, India
| | - Salman A Alrokayan
- Research Chair for Biomedical Application of Nanomaterials, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia.,Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Fahad N Almajhdi
- Center of Excellence in Biotechnology Research, College of Science, King Saud University, Riyadh, Saudi Arabia.,Botany and Microbiology Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Tajamul Hussain
- Research Chair for Biomedical Application of Nanomaterials, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia.,Center of Excellence in Biotechnology Research, College of Science, King Saud University, Riyadh, Saudi Arabia
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5
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Amissah-Arthur MB, Baah W. Methotrexate-Induced Pancytopenia and Mucositis Caused by Medication Error. Ghana Med J 2020; 54:68-71. [PMID: 32863415 PMCID: PMC7445697 DOI: 10.4314/gmj.v54i1.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of methotrexate in routine clinical practice is becoming more common among specialties such as rheumatology, dermatology, oncology and obstetrics. General clinicians are increasingly encountering patients on this drug. Though it has a high safety profile, there is a recognised risk of acute toxicity or long-term complications associated with its use, which can be worsened by several factors such as advanced age, moderate to severe renal impairment, low folate level and/or inadequate folate supplementation, hypoalbuminaemia, polypharmacy causing drug-drug interactions and wrongful administration. We present a case of a 45-year old woman with rheumatoid arthritis who presented with acute pancytopaenia and mucositis due to methotrexate toxicity. We highlight its peculiar dosing regimen to minimise prescribing errors.
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Affiliation(s)
| | - Winifred Baah
- Korle Bu Teaching Hospital, Department of Medicine and Therapeutics, Accra, Ghana
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Wang G, Peng X. A Review of Clinical Applications and Side Effects of Methotrexate in Ophthalmology. J Ophthalmol 2020; 2020:1537689. [PMID: 32850138 PMCID: PMC7439192 DOI: 10.1155/2020/1537689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022] Open
Abstract
Methotrexate (MTX) is a folate analog widely used against a range of diseases including malignancies and autoimmune disorders. Its high effectiveness-price ratio also won extensive application in ophthalmology. On the other hand, although MTX has an excellent pharmacological efficacy, MTX associated side effects in clinical use, which vary from patient to patient, are nonnegligible. There is no comparatively systematic review on MTX associated side effects and its risk factors. This review aimed to reveal novel clinical approaches of MTX and its adverse effects in order to provide a reference for ophthalmic scholars in clinical application of MTX.
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Affiliation(s)
- Ge Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Xiaoyan Peng
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
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7
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Gurram B, Patel AS. Recent advances in understanding and managing pediatric inflammatory bowel disease. F1000Res 2019; 8. [PMID: 31885858 PMCID: PMC6913196 DOI: 10.12688/f1000research.19609.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/07/2022] Open
Abstract
The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.
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Affiliation(s)
- Bhaskar Gurram
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ashish S. Patel
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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8
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Manappallil RG, Prasan D, Peringat J, Biju IK. Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury. BMJ Case Rep 2018; 2018:bcr-2018-224722. [PMID: 29871962 PMCID: PMC5990089 DOI: 10.1136/bcr-2018-224722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 12/17/2022] Open
Abstract
Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.
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Affiliation(s)
| | - Durga Prasan
- Medical Oncology, Baby Memorial Hospital, Calicut, Kerala, India
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9
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Asymmetric Dimethyl Arginine as a Biomarker of Atherosclerosis in Rheumatoid Arthritis. Mediators Inflamm 2018; 2018:3897295. [PMID: 29576746 PMCID: PMC5822828 DOI: 10.1155/2018/3897295] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease is the main cause of morbidity and mortality in rheumatoid arthritis (RA). Despite the advent on new drugs targeting the articular manifestations, the burden of cardiovascular disease is still an unmet need in the management of RA. The pathophysiology of accelerated atherosclerosis associated to RA is not yet fully understood, and reliable and specific markers of early cardiovascular involvement are still lacking. Asymmetric dimethylarginine is gaining attention for its implication in the pathogenesis of endothelial dysfunction and as biomarkers of subclinical atherosclerosis. Moreover, the metabolic pathway of methylarginines offers possible targets for therapeutic interventions to decrease the cardiovascular risk. The purpose of this review is to describe the main causes of increased methylarginine levels in RA, their implication in accelerated atherosclerosis, the possible role as biomarkers of cardiovascular risk, and finally the available data on current pharmacological treatment.
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10
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Sparks JA, Barbhaiya M, Karlson EW, Ritter SY, Raychaudhuri S, Corrigan CC, Lu F, Selhub J, Chasman DI, Paynter NP, Ridker PM, Solomon DH. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: Rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis Rheum 2017; 47:133-142. [PMID: 28284844 PMCID: PMC5765986 DOI: 10.1016/j.semarthrit.2017.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND The role of low dose methotrexate (LDM) in potential serious toxicities remains unclear despite its common use. Prior observational studies investigating LDM toxicity compared LDM to other active drugs. Prior placebo-controlled clinical trials of LDM in inflammatory conditions were not large enough to investigate toxicity. The Cardiovascular Inflammation Reduction Trial (CIRT) is an ongoing NIH-funded, randomized, double-blind, placebo-controlled trial of LDM in the secondary prevention of cardiovascular disease. We describe here the rationale and design of the CIRT-Adverse Events (CIRT-AE) ancillary study which aims to investigate adverse events within CIRT. DESIGN CIRT will randomize up to 7000 participants with cardiovascular disease and no systemic rheumatic disease to either LDM (target dose: 15-20mg/week) or placebo for an average follow-up period of 3-5 years; subjects in both treatment arms receive folic acid 1mg daily for 6 days each week. The primary endpoints of CIRT include recurrent cardio vascular events, incident diabetes, and all-cause mortality, and the ancillary CIRT-AE study has been designed to adjudicate other clinically important adverse events including hepatic, gastrointestinal, respiratory, hematologic, infectious, mucocutaneous, oncologic, renal, neurologic, and musculoskeletal outcomes. Methotrexate polyglutamate levels and genome-wide single nucleotide polymorphisms will be examined for association with adverse events. SUMMARY CIRT-AE will comprehensively evaluate potential LDM toxicities among subjects with cardiovascular disease within the context of a large, ongoing, double-blind, placebo-controlled trial. This information may lead to a personalized approach to monitoring LDM in clinical practice.
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Affiliation(s)
- Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Medha Barbhaiya
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Susan Y Ritter
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Soumya Raychaudhuri
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA
| | - Cassandra C Corrigan
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Fengxin Lu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Jacob Selhub
- Jean Mayer USDA, Human Nutrition Center on Aging, Tufts University, Boston, MA
| | - Daniel I Chasman
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Nina P Paynter
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Paul M Ridker
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Daniel H Solomon
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
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11
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Lourdudoss C, Wolk A, Nise L, Alfredsson L, Vollenhoven RV. Are dietary vitamin D, omega-3 fatty acids and folate associated with treatment results in patients with early rheumatoid arthritis? Data from a Swedish population-based prospective study. BMJ Open 2017; 7:e016154. [PMID: 28601838 PMCID: PMC5541601 DOI: 10.1136/bmjopen-2017-016154] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Dietary intake of vitamin D and omega-3 fatty acids (FA) may be associated with superior response to antirheumatic treatments. In addition, dietary folate intake may be associated with worse response to methotrexate (MTX). The aim of this study was to investigate the association between dietary vitamin D, omega-3 FA, folate and treatment results of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA). METHODS This prospective study was based on data from the Epidemiological Investigation of Rheumatoid Arthritis (EIRA) study, and included 727 patients with early RA from 10 hospitals in Sweden. Data on dietary vitamin D, omega-3 FA and folate intake based on food frequency questionnaires were linked with data on European League Against Rheumatism (EULAR) response after 3 months of DMARD treatment. Associations between vitamin D, omega-3 FA, folate and EULAR response were analysed with logistic regression adjusted for potential confounders. RESULTS The majority of patients (89.9%) were initially treated with MTX monotherapy and more than half (56.9%) with glucocorticoids. Vitamin D and omega-3 FA were associated with good EULAR response (OR 1.80 (95% CI 1.14 to 2.83) and OR 1.60 (95% CI 1.02 to 2.53), respectively). Folate was not significantly associated with EULAR response (OR 1.20 (95% CI 0.75 to 1.91)). Similar results were seen in a subgroup of patients who were initially treated with MTX monotherapy at baseline. CONCLUSIONS Higher intake of dietary vitamin D and omega-3 FA during the year preceding DMARD initiation may be associated with better treatment results in patients with early RA. Dietary folate intake was not associated with worse or better response to treatment, especially to MTX. Our results suggest that some nutrients may be associated with enhanced treatment results of DMARDs.
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Affiliation(s)
| | - Alicja Wolk
- Department of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lena Nise
- Department of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars Alfredsson
- Department of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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12
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Abstract
The nutrient folate is essential for normal cell growth and development. Enzymes that require folate as a cofactor have been common targets for chemotherapeutic agents. Limited clinical guidance is available regarding optimal levels of dietary or supplemental folate intake during antifolate chemotherapy to meet the goals of minimizing treatment-related toxicity yet preserving treatment effectiveness. Patients with higher folate intake may experience less treatment-related toxicities; however, the concern is that folate may interfere with the effectiveness of the antifolate treatment and possibly support tumor growth. This article will review folate and antifolate metabolism and review the current body of knowledge regarding the interactions between folates and antifolates. Future research in this area should include evaluation of pretreatment folate status and dietary and supplemental folate intake before, during, and after treatment.
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Affiliation(s)
- Kim Robien
- Cancer Prevention Program, Fred Hutchinson Cancer Research Center, PO Box 19024, M4-B402 Seattle, Washington 98109-1024, USA.
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13
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Hawwa AF, AlBawab A, Rooney M, Wedderburn LR, Beresford MW, McElnay JC. Methotrexate polyglutamates as a potential marker of adherence to long-term therapy in children with juvenile idiopathic arthritis and juvenile dermatomyositis: an observational, cross-sectional study. Arthritis Res Ther 2015; 17:295. [PMID: 26493320 PMCID: PMC4619187 DOI: 10.1186/s13075-015-0814-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022] Open
Abstract
Introduction Methotrexate (MTX) is a cornerstone of treatment in a wide variety of inflammatory conditions, including juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). However, owing to its narrow therapeutic index and the considerable interpatient variability in clinical response, monitoring of adherence to MTX is important. The present study demonstrates the feasibility of using methotrexate polyglutamates (MTXPGs) as a biomarker to measure adherence to MTX treatment in children with JIA and JDM. Methods Data were collected prospectively from a cohort of 48 children (median age 11.5 years) who received oral or subcutaneous (SC) MTX therapy for JIA or JDM. Dried blood spot samples were obtained from children by finger pick at the clinic or via self- or parent-led sampling at home, and they were analysed to determine the variability in MTXPG concentrations and assess adherence to MTX therapy. Results Wide fluctuations in MTXPG total concentrations (>2.0-fold variations) were found in 17 patients receiving stable weekly doses of MTX, which is indicative of nonadherence or partial adherence to MTX therapy. Age (P = 0.026) and route of administration (P = 0.005) were the most important predictors of nonadherence to MTX treatment. In addition, the study showed that MTX dose and route of administration were significantly associated with variations in the distribution of MTXPG subtypes. Higher doses and SC administration of MTX produced higher levels of total MTXPGs and selective accumulation of longer-chain MTXPGs (P < 0.001 and P < 0.0001, respectively). Conclusions Nonadherence to MTX therapy is a significant problem in children with JIA and JDM. The present study suggests that patients with inadequate adherence and/or intolerance to oral MTX may benefit from SC administration of the drug. The clinical utility of MTXPG levels to monitor and optimise adherence to MTX in children has been demonstrated. Trial registration ISRCTN Registry identifier: ISRCTN93945409. Registered 2 December 2011.
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Affiliation(s)
- Ahmed F Hawwa
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK. .,Aston Pharmacy School, Aston University, Birmingham, UK.
| | - AbdelQader AlBawab
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK. .,Faculty of Pharmacy, Al Zaytoonah University, Amman, Jordan.
| | - Madeleine Rooney
- Centre for Infection and Immunity, School of Medicine and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
| | - Lucy R Wedderburn
- Institute of Child Health, University College London, London, UK. .,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, University College London Hospital, London, UK. .,Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, The Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK.
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Romão VC, Lima A, Bernardes M, Canhão H, Fonseca JE. Three decades of low-dose methotrexate in rheumatoid arthritis: can we predict toxicity? Immunol Res 2015; 60:289-310. [PMID: 25391609 DOI: 10.1007/s12026-014-8564-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Methotrexate (MTX) is the anchor disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis (RA) treatment. It is used in monotherapy and/or in combination with other synthetic or biological DMARDs, and is known to have the best cost-effectiveness and efficacy/toxicity ratios. However, toxicity is still a concern, with a significant proportion of patients interrupting long-term treatment due to the occurrence of MTX-related adverse drug reactions (ADRs), which are the main cause of drug withdrawal. Despite the extensive accumulated experience in the last three decades, it is still impossible in routine clinical practice to identify patients prone to develop MTX toxicity. While clinical and biological variables, including folate supplementation, partially help to minimize MTX-related ADRs, the advent of pharmacogenomics could provide further insight into risk stratification and help to optimize drug monitoring and long-term retention. In this paper, we aimed to review and summarize current data on low-dose MTX-associated toxicity, its prevention and predictors, keeping in mind practical RA clinical care.
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Affiliation(s)
- Vasco C Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Edifício Egas Moniz, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
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Dhir V, Sandhu A, Kaur J, Pinto B, Kumar P, Kaur P, Gupta N, Sood A, Sharma A, Sharma S. Comparison of two different folic acid doses with methotrexate--a randomized controlled trial (FOLVARI Study). Arthritis Res Ther 2015; 17:156. [PMID: 26063325 PMCID: PMC4483203 DOI: 10.1186/s13075-015-0668-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction There is reasonable evidence that folic acid 5–10 mg per week leads to reduction in methotrexate (MTX) toxicity in rheumatoid arthritis (RA). However, this is based on studies conducted with lower MTX dosage than used currently. It is unclear whether higher doses of folic acid may be better in reducing toxicity. Methods This was a double-blind randomized controlled trial of 24 weeks duration. To be eligible, patients should have rheumatoid arthritis (1987 American College of Rheumatology criteria), be 18–75 years of age, not be on MTX and have active disease as defined by ‘Modified Disease Activity Score using three variables’ (DAS28(3)) > 3.2. MTX was started at 10 mg/week and escalated to 25 mg/week by 12 weeks. Folic acid was given at a dose of 10 mg (FA10) or 30 mg per week (FA30). Co-primary endpoints were incidence of toxicity (undesirable symptoms and laboratory abnormalities) and change in disease activity by 24 weeks. Intention-to-treat and per-protocol analyses were performed. Results Among 100 patients enrolled, 51 and 49 were randomized to FA10 and FA30 respectively. By 24 weeks, there were 6 patient withdrawals in either group and mean(±SD) dose of MTX was 22.8 ± 4.4 and 21.4 ± 4.6 mg per week (p = 0.1). Frequency of patients with undesirable symptoms was non-significantly lower by 7.4 % (95 % confidence interval −27.4 to 12.7 %) in FA10 compared to FA30. There was also no difference in frequency of transaminitis (>Upper limit of normal (ULN)) (42.6, 45.7 %, p = 0.7) or transminitis as per primary endpoint (>2xULN) (10.6, 8.7 %, p = 1.0) or cytopenias (4.3, 4.3 %, p = 0.9). There was no difference in the primary end-point of occurrence of any adverse effect (symptom or laboratory) in FA10 and FA30 (46.8, 54.3 %, p = 0.5). At 24 weeks, DAS28(3) declined in both groups by a similar extent (−1.1 ± 1.0, −1.3 ± 1.0, p = 0.2) and ‘European League Against Rheumatism’ good or moderate response occurred in 56.9 and 67.4 % (p = 0.3). Conclusions Even with the high doses of MTX used in current practice, there was no additional benefit (or harm) of a higher dose of folic acid (30 mg/week) over a usual dose (10 mg/week). Trial Registration Clinicaltrials.gov NCT01583959 Registered 15 March 2012
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Affiliation(s)
- Varun Dhir
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Amit Sandhu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Jasbinder Kaur
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India.
| | - Benzeeta Pinto
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Phani Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Prabhdeep Kaur
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Nidhi Gupta
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Ankita Sood
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
| | - Shefali Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160020, India.
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Specific management of post-chikungunya rheumatic disorders: a retrospective study of 159 cases in Reunion Island from 2006-2012. PLoS Negl Trop Dis 2015; 9:e0003603. [PMID: 25760632 PMCID: PMC4356515 DOI: 10.1371/journal.pntd.0003603] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 02/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background Since 2003, the tropical arthritogenic chikungunya (CHIK) virus has become an increasingly medical and economic burden in affected areas as it can often result in long-term disabilities. The clinical spectrum of post-CHIK (pCHIK) rheumatic disorders is wide. Evidence-based recommendations are needed to help physicians manage the treatment of afflicted patients. Patients and methods We conducted a 6-year case series retrospective study in Reunion Island of patients referred to a rheumatologist due to continuous rheumatic or musculoskeletal pains that persisted following CHIK infection. These various disorders were documented in terms of their clinical and therapeutic courses. Post-CHIK de novo chronic inflammatory rheumatisms (CIRs) were identified according to validated criteria. Results We reviewed 159 patient medical files. Ninety-four patients (59%) who were free of any articular disorder prior to CHIK met the CIR criteria: rheumatoid arthritis (n=40), spondyloarthritis (n=33), undifferentiated polyarthritis (n=21). Bone lesions detectable by radiography occurred in half of the patients (median time: 3.5 years pCHIK). A positive therapeutic response was achieved in 54 out of the 72 patients (75%) who were treated with methotrexate (MTX). Twelve out of the 92 patients (13%) received immunomodulatory biologic agents due to failure of contra-indication of MTX treatment. Other patients mainly presented with mechanical shoulder or knee disorders, bilateral distal polyarthralgia that was frequently associated with oedema at the extremities and tunnel syndromes. These pCHIK musculoskeletal disorders (MSDs) were managed with pain-killers, local and/or general anti-inflammatory drugs, and physiotherapy. Conclusion Rheumatologists in Reunion Island managed CHIK rheumatic disorders in a pragmatic manner following the outbreak in 2006. This retrospective study describes the common mechanical and inflammatory pCHIK disorders. We provide a diagnostic and therapeutic algorithm to help physicians deal with chronic patients, and to limit both functional and economic impacts. The therapeutic indication of MTX in pCHIK CIR could be approved in future efficacy trials. With a 6-year insight, we extensively and retrospectively describe clinical profiles and specific treatments of mechanical and inflammatory post-chikungunya rheumatic disorders. In the current context of chikungunya’s global spread, we provide the first diagnostic and therapeutic algorithm to guide physicians according to the amount of time that has elapsed since the acute CHIK infection.
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The possibilities and principles of methotrexate treatment of psoriasis - the updated knowledge. Postepy Dermatol Alergol 2014; 31:392-400. [PMID: 25610355 PMCID: PMC4293394 DOI: 10.5114/pdia.2014.47121] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 11/10/2014] [Accepted: 11/25/2014] [Indexed: 12/14/2022] Open
Abstract
Psoriasis is a chronic multifactorial disease affecting 2–4% of the general population. Due to its nature, psoriasis has a negative impact on the quality of life of patients. Therefore, the choice of an appropriate and individually tailored treatment controlling the symptoms of the disorder is necessary and continues to be a challenge for dermatologists. Therapeutic modalities in psoriasis should on the one hand be effective and on the other hand present a good safety profile. Methotrexate (MTX) is one of treatment options for psoriasis and can be administered both as monotherapy or in combination schemes. The paper presents the current state of knowledge about the possible treatment of psoriatic patients with MTX according to contemporary guidelines.
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Lima A, Seabra V, Bernardes M, Azevedo R, Sousa H, Medeiros R. Role of key TYMS polymorphisms on methotrexate therapeutic outcome in portuguese rheumatoid arthritis patients. PLoS One 2014; 9:e108165. [PMID: 25279663 PMCID: PMC4184792 DOI: 10.1371/journal.pone.0108165] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/19/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Therapeutic outcome of rheumatoid arthritis (RA) patients treated with methotrexate (MTX) can be modulated by thymidylate synthase (TS) levels, which may be altered by genetic polymorphisms in TS gene (TYMS). This study aims to elucidate the influence of TYMS polymorphisms in MTX therapeutic outcome (regarding both clinical response and toxicity) in Portuguese RA patients. METHODS Clinicopathological data from 233 Caucasian RA patients treated with MTX were collected, outcomes were defined and patients were genotyped for the following TYMS polymorphisms: 1) 28 base pairs (bp) variable number tandem repeat (rs34743033); 2) single nucleotide polymorphism C>G (rs2853542); and 3) 6 bp sequence deletion (1494del6, rs34489327). Chi-square and binary logistic regression analyses were performed, using genotype and haplotype-based approaches. RESULTS Considering TYMS genotypes, 3R3R (p = 0.005, OR = 2.34), 3RC3RG (p = 0.016, OR = 3.52) and 6bp- carriers (p = 0.011, OR = 1.96) were associated with non-response to MTX. Multivariate analysis confirmed the increased risk for non-response to MTX in 6bp- carriers (p = 0.016, OR = 2.74). Data demonstrated that TYMS polymorphisms were in linkage disequilibrium (p<0.00001). Haplotype multivariate analysis revealed that haplotypes harboring both 3R and 6bp- alleles were associated with non-response to MTX. Regarding MTX-related toxicity, no statistically significant differences were observed in relation to TYMS genotypes and haplotypes. CONCLUSION Our study reveals that TYMS polymorphisms could be important to help predicting clinical response to MTX in RA patients. Despite the potential of these findings, translation into clinical practice needs larger studies to confirm these evidences.
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Affiliation(s)
- Aurea Lima
- CESPU, Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Pharmaceutical Sciences, Higher Institute of Health Sciences-North (ISCS-N), Gandra PRD, Portugal
- Molecular Oncology Group CI, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
- Abel Salazar Institute for the Biomedical Sciences (ICBAS) of University of Porto, Porto, Portugal
- * E-mail:
| | - Vítor Seabra
- CESPU, Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Pharmaceutical Sciences, Higher Institute of Health Sciences-North (ISCS-N), Gandra PRD, Portugal
| | - Miguel Bernardes
- Faculty of Medicine of University of Porto (FMUP), Porto, Portugal
- Rheumatology Department of São João Hospital Center, Porto, Portugal
| | - Rita Azevedo
- Molecular Oncology Group CI, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
- Faculty of Medicine of University of Porto (FMUP), Porto, Portugal
| | - Hugo Sousa
- Molecular Oncology Group CI, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
- Faculty of Medicine of University of Porto (FMUP), Porto, Portugal
- Virology Service, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology Group CI, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
- Abel Salazar Institute for the Biomedical Sciences (ICBAS) of University of Porto, Porto, Portugal
- Virology Service, Portuguese Institute of Oncology of Porto (IPO-Porto), Porto, Portugal
- Research Department-Portuguese League Against Cancer (LPCC-NRNorte), Porto, Portugal
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den Boer E, de Rotte MC, Pluijm SM, Heil SG, Hazes JM, de Jonge R. Determinants of Erythrocyte Methotrexate Polyglutamate Levels in Rheumatoid Arthritis. J Rheumatol 2014; 41:2167-78. [DOI: 10.3899/jrheum.131290] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective.Low-dose methotrexate (MTX) is the anchor drug in the treatment for rheumatoid arthritis (RA). Response to MTX is related to the intracellular MTX-polyglutamate (MTX-PG) levels and little is known about its determinants. We aimed to define the determinants of erythrocyte MTX-PG concentrations in 2 prospective cohorts of patients with RA.Methods.Patients with RA treated with MTX from 2 longitudinal cohorts were included: 93 from the MTX-R study (Rotterdam, the Netherlands derivation cohort), and 247 from the treatment in Rotterdam Early Arthritis Cohort study (validation cohort). MTX-PG concentrations were measured at 3 months of treatment using liquid chromatography/mass spectrometry. The MTX-PG were used as outcome measure. Various sociodemographic, clinical, biochemical, and genetic factors were assessed at baseline. Associations with MTX-PG levels were analyzed using multivariate regression analysis.Results.Age was positively associated with MTX-PG1 (stβ 0.23, p = 0.033) and total MTX-PG (stβ 0.23, p = 0.018) in the derivation cohort, and with all MTX-PG in the validation cohort (MTX-PG1: stβ 0.13, p = 0.04; MTX-PG2: stβ 0.21, p = 0.001; MTX-PG3: stβ 0.22, p < 0.001; MTX-PG4+5: stβ 0.25, p < 0.001; and total MTX-PG: stβ 0.32, p < 0.001). Erythrocyte folate levels were positively associated with MTX-PG3 (stβ 0.3, p = 0.021) and total MTX-PG levels (stβ 0.32, p = 0.022) in the derivation cohort, which was replicated for MTX-PG3 (stβ 0.15, p = 0.04) in the validation cohort. Patients with the folylpolyglutamate synthase (FPGS) rs4451422 wild-type genotype had higher concentrations of MTX-PG3 (p < 0.05), MTX-PG4+5 (p < 0.05), and total MTX-PG (p < 0.05) in both cohorts. In the combined cohort, MTX dose was positively associated with levels of MTX-PG3 (stβ 0.23, p < 0.001), MTX-PG4+5 (stβ 0.30, p < 0.001), and total MTX-PG (stβ 0.20, p = 0.002), but negatively associated with MTX-PG2 levels (stβ −0.22, p < 0.001).Conclusion.Our prospective study shows that higher age, higher MTX dose, higher erythrocyte folate status, and the FPGS rs4451422 wild-type genotype are associated with higher MTX-PG concentrations. While only up to 21% of interpatient variability can be explained by these determinants, this knowledge may aid in the development of personalized treatment in RA.
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Optimizing pharmacotherapy of systemic lupus erythematosus: the pharmacist role. Int J Clin Pharm 2014; 36:684-92. [DOI: 10.1007/s11096-014-9966-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 05/27/2014] [Indexed: 01/22/2023]
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Prediction of methotrexate clinical response in Portuguese rheumatoid arthritis patients: implication of MTHFR rs1801133 and ATIC rs4673993 polymorphisms. BIOMED RESEARCH INTERNATIONAL 2014; 2014:368681. [PMID: 24967362 PMCID: PMC4055378 DOI: 10.1155/2014/368681] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 01/17/2023]
Abstract
Objective. Methotrexate (MTX), the most used drug in rheumatoid arthritis (RA) treatment, showing variability in clinical response, is often associated with genetic polymorphisms. This study aimed to elucidate the role of methylenetetrahydrofolate reductase (MTHFR) C677T and aminoimidazole carboxamide adenosine ribonucleotide transformylase (ATIC) T675C polymorphisms and clinicopathological variables in clinical response to MTX in Portuguese RA patients. Methods. Study included 233 RA patients treated with MTX for at least six months. MTHFR C677T and ATIC T675C polymorphisms were genotyped and clinicopathological variables were collected. Statistical analyses were performed and binary logistic regression method adjusted to possible confounding variables. Results. Multivariate analyses demonstrated that MTHFR 677TT (OR = 4.63; P = 0.013) and ATIC 675T carriers (OR = 5.16; P = 0.013) were associated with over 4-fold increased risk for nonresponse. For clinicopathological variables, noncurrent smokers (OR = 7.98; P = 0.001), patients positive to anti-cyclic citrullinated peptide (OR = 3.53; P = 0.004) and antinuclear antibodies (OR = 2.28; P = 0.045), with higher health assessment questionnaire score (OR = 2.42; P = 0.007), and nonsteroidal anti-inflammatory drug users (OR = 2.77; P = 0.018) were also associated with nonresponse. Contrarily, subcutaneous administration route (OR = 0.11; P < 0.001) was associated with response. Conclusion. Our study suggests that MTHFR C677T and ATIC T675C genotyping combined with clinicopathological data may help to identify patients whom will not benefit from MTX treatment and, therefore, assist clinicians in personalizing RA treatment.
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Gurevitz SL, Snyder JA, Wessel EK, Frey J, Williamson BA. Systemic Lupus Erythematosus: A Review of the Disease and Treatment Options. ACTA ACUST UNITED AC 2013; 28:110-21. [DOI: 10.4140/tcp.n.2013.110] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Involvement of Multiple Transporters-mediated Transports in Mizoribine and Methotrexate Pharmacokinetics. Pharmaceuticals (Basel) 2012; 5:802-36. [PMID: 24280676 PMCID: PMC3763673 DOI: 10.3390/ph5080802] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 07/25/2012] [Accepted: 08/07/2012] [Indexed: 12/19/2022] Open
Abstract
Mizoribine is administered orally and excreted into urine without being metabolized. Many research groups have reported a linear relationship between the dose and peak serum concentration, between the dose and AUC, and between AUC and cumulative urinary excretion of mizoribine. In contrast, a significant interindividual variability, with a small intraindividual variability, in oral bioavailability of mizoribine is also reported. The interindividual variability is mostly considered to be due to the polymophisms of transporter genes. Methotrexate (MTX) is administered orally and/or by parenteral routes, depending on the dose. Metabolic enzymes and multiple transporters are involved in the pharmacokinetics of MTX. The oral bioavailability of MTX exhibits a marked interindividual variability and saturation with increase in the dose of MTX, with a small intraindividual variability, where the contribution of gene polymophisms of transporters and enzymes is suggested. Therapeutic drug monitoring of both mizoribine and MTX is expected to improve their clinical efficacy in the treatment of rheumatoid arthritis.
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Mouterde G, Baillet A, Gaujoux-Viala C, Cantagrel A, Wendling D, Le Loët X, Schaeverbeke T. Optimizing methotrexate therapy in rheumatoid arthritis: A systematic literature review. Joint Bone Spine 2011; 78:587-92. [DOI: 10.1016/j.jbspin.2011.01.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 01/27/2011] [Indexed: 11/30/2022]
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Micha R, Imamura F, Wyler von Ballmoos M, Solomon DH, Hernán MA, Ridker PM, Mozaffarian D. Systematic review and meta-analysis of methotrexate use and risk of cardiovascular disease. Am J Cardiol 2011; 108:1362-70. [PMID: 21855836 DOI: 10.1016/j.amjcard.2011.06.054] [Citation(s) in RCA: 373] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/13/2011] [Accepted: 06/13/2011] [Indexed: 12/11/2022]
Abstract
Inflammation predicts risk for cardiovascular disease (CVD) events, but the relation of drugs that directly target inflammation with CVD risk is not established. Methotrexate is a disease-modifying antirheumatic drug broadly used for the treatment of chronic inflammatory disorders. A systematic review and meta-analysis of evidence of relations of methotrexate with CVD occurrence were performed. Cohorts, case-control studies, and randomized trials were included if they reported associations between methotrexate and CVD risk. Inclusions and exclusions were independently adjudicated, and all data were extracted in duplicate. Pooled effects were calculated using inverse variance-weighted meta-analysis. Of 694 identified publications, 10 observational studies in which methotrexate was administered in patients with rheumatoid arthritis, psoriasis, or polyarthritis met the inclusion criteria. Methotrexate was associated with a 21% lower risk for total CVD (n = 10 studies, 95% confidence interval [CI] 0.73 to 0.87, p <0.001) and an 18% lower risk for myocardial infarction (n = 5, 95% CI 0.71 to 0.96, p = 0.01), without evidence for statistical between-study heterogeneity (p = 0.30 and p = 0.33, respectively). Among prespecified sources of heterogeneity explored, stronger associations were observed in studies that adjusted for underlying disease severity (relative risk 0.64, 95% CI 0.43 to 0.96, p <0.01) and for other concomitant medication (relative risk 0.73, 95% CI 0.63 to 0.84, p <0.001). Publication bias was potentially evident (funnel plot, Begg's test, p = 0.06); excluding studies with extreme risk estimates did not, however, alter results (relative risk 0.81, 95% CI 0.74 to 0.89). In conclusion, methotrexate use is associated with a lower risk for CVD in patients with chronic inflammation. These findings suggest that a direct treatment of inflammation may reduce CVD risk.
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Mañosa M, García V, Castro L, García-Bosch O, Chaparro M, Barreiro-de Acosta M, Carpio D, Aguas M. Methotrexate in ulcerative colitis: a Spanish multicentric study on clinical use and efficacy. J Crohns Colitis 2011; 5:397-401. [PMID: 21939912 DOI: 10.1016/j.crohns.2011.03.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Few data are available on the efficacy of methotrexate (MTX) in ulcerative colitis (UC). AIM To evaluate the efficacy and safety of MTX in UC patients. PATIENTS AND METHODS UC patients who had been treated with MTX were identified from the databases of 8 Spanish IBD referral hospitals. Patients were included in the study if they received MTX for steroid dependency or steroid refractoriness. Therapeutic success was defined as the absence of UC-related symptoms, complete steroid withdrawal and no requirement of rescue therapies within the first 6 months after starting MTX. RESULTS Forty patients were included, 70% treated for steroid dependency and 27% for steroid refractoriness. Thiopurines had been previously attempted in 87.5% of patients. The median dose of MTX used for induction was 25mg (IIQ 17.5-25) weekly given parenterally in 82.5% of cases. Eighty-five percent of patients were on steroids when MTX was started. Forty-five percent of patients met criteria for therapeutic success. Initial treatment failures were mainly due to inefficacy (50%) or intolerance (36%). After a median follow-up of 28 months (IQR 22-47), 38% of patients with initial therapeutic success required new steroid courses, 22% started biological therapy, and only 1 patient required colectomy. The cumulative probability of maintaining steroid-free clinical remission was 60%, 48%, and 35% at 6, 12, and 24 months after starting MTX, respectively. Eleven patients (27.5%) experienced adverse events, leading to MTX discontinuation in only 8 of them. CONCLUSIONS MTX appears to be effective to maintain clinical remission in UC, at least in the short-term, with an acceptable safety profile.
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Affiliation(s)
- Míriam Mañosa
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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KEYSTONE EDWARDC, SHIRINSKY VALERYS, SIMON LEES, PEDDER SIMON, HEWITT LARTHUR. Efficacy and Safety of CH-1504, a Metabolically Stable Antifolate, in Patients with Active Rheumatoid Arthritis: Results of a Phase II Multicenter Randomized Study. J Rheumatol 2011; 38:1875-83. [DOI: 10.3899/jrheum.101038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To investigate the potential efficacy, safety, and tolerability of daily use of CH-1504 in patients with active rheumatoid arthritis (RA). US National Institutes of Health database no. NCT00658047.Methods.In our phase II randomized double-blind double-dummy study, patients naive to methotrexate (MTX; n = 201) and having moderate to severe RA received either CH-1504 (0.25 mg, 0.5 mg, or 1.0 mg once-daily oral doses) or MTX (titrated to 20.0 mg once-weekly oral doses). All received weekly 10-mg folate supplementation. Efficacy and safety were assessed at 2, 4, 8, and 12 weeks, with a treatment-free followup at 16 weeks. Safety and tolerability were assessed. Primary efficacy endpoint was proportion of patients achieving ACR20 response at Week 12. Secondary endpoints included difference from baseline in the 28-joint Disease Activity Score (DAS28) and individual components of the American College of Rheumatology (ACR) composite index.Results.Demographic characteristics were similar in all treatment groups: mean age 54.3 ± 11.4 years, female sex 87%, mean baseline DAS28 6.6 ± 0.9. At Week 12, CH-1504 demonstrated comparable efficacy compared to MTX as measured by ACR20, DAS28, and ACR composite core-set measures, including tender and swollen joints. No dose-response relationship was observed. Adverse events across treatment groups were mild. Liver enzyme levels increased from baseline to Week 16 in the MTX group, with qualitatively lesser increases in the CH-1504 groups. Two patients in the MTX group withdrew because of gastrointestinal-related adverse events. CH-1504 appeared safe and well tolerated at all dose levels.Conclusion.CH-1504 has comparable efficacy to MTX and is safe and well tolerated. Metabolically stable antifolates are a promising therapeutic option that warrants further study.
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Pathirana D, Ormerod AD, Saiag P, Smith C, Spuls PI, Nast A, Barker J, Bos JD, Burmester GR, Chimenti S, Dubertret L, Eberlein B, Erdmann R, Ferguson J, Girolomoni G, Gisondi P, Giunta A, Griffiths C, Hönigsmann H, Hussain M, Jobling R, Karvonen SL, Kemeny L, Kopp I, Leonardi C, Maccarone M, Menter A, Mrowietz U, Naldi L, Nijsten T, Ortonne JP, Orzechowski HD, Rantanen T, Reich K, Reytan N, Richards H, Thio HB, van de Kerkhof P, Rzany B. European S3-Guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009; 23 Suppl 2:1-70. [DOI: 10.1111/j.1468-3083.2009.03389.x] [Citation(s) in RCA: 467] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Braun J, Zochling J, Märker-Hermann E, Stucki G, Böhm H, Rudwaleit M, Zeidler H, Sieper J. [Recommendations for the management of ankylosing spodylitis after ASAS/EULAR. Evaluation in the German language area]. Z Rheumatol 2009; 65:728-42. [PMID: 17119900 DOI: 10.1007/s00393-006-0119-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Our aim was to adapt and implement the evidence based recommendations for the management of ankylosing spodylitis (AS) of the "Assessments in AS" (ASAS) International Working Group together with the European League Against Rheumatism (EULAR) within the framework of a competence network (CN) in rheumatology in the German language area. METHODS The ASAS/EULAR project calculated the effective size (ES), rate ratio, number of patients requiring treatment (number needed to treat, NNT) and the incremental cost-effectiveness ratio (ICER). The strength of the recommendations was determined through the evidence level found in the literature, the risk-benefit trade-off and the clinical experience of the experts. The recommendations were recently published in English. All of the centers taking part in the study area Spondyloarthritis (SpA) CN, as well as an additional 35 experts, were sent the English manuscript. All 35 participants were asked to evaluate the ten main management recommendations on a scale from 0 to 10. RESULTS The recommendations encompass the use of drugs such as non-steroid anti-inflammatories (NSAR), which, along with conventional NSAR include coxibs and the parallel application of gastroprotectives, so called disease-modifying anti-rheumatic drugs, biologicals, simple analgesics, local and systematic glucocorticoids, non-drug therapies (such as patient training, medical training therapy and physiotherapy), in addition to surgical treatment methods. Moreover, three general recommendations were formulated and a therapy scheme created, taking into consideration the various clinical manifestations. The strength of the ASAS/EULAR recommendations was generally high. There was a marked consensus between the German speaking experts and the international proposal: a mean of 9.13 with relatively low variation between the recommendations. SUMMARY Ten key recommendations for the treatment of AS were developed. These were strengthened by a systematic search of the literature and by expert consensus. The large group of German speaking experts were largely in agreement with the proposal. This can be seen as a starting point for the dissemination and implementation of the recommendations.
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Affiliation(s)
- J Braun
- Rheumazentrum-Ruhrgebiet, St. Josefs-Krankenhaus, Landgrafenstrasse 15, 44652, Herne, Deutschland.
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Kontzias A, Efthimiou P. Adult-onset Still's disease: pathogenesis, clinical manifestations and therapeutic advances. Drugs 2008; 68:319-37. [PMID: 18257609 DOI: 10.2165/00003495-200868030-00005] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Adult-onset Still's disease (AOSD) is a rare, systemic inflammatory disease of unknown aetiology, characterized by daily high spiking fevers, evanescent rash and arthritis. Our objective was to review the most recent medical literature regarding advances in the understanding of disease pathogenesis, diagnosis and treatment. There is no single diagnostic test for AOSD, and diagnosis is based on clinical criteria and usually necessitates the exclusion of infectious, neoplastic and autoimmune diseases. Laboratory tests are nonspecific and reflect heightened immunological activity with leukocytosis, elevated acute phase reactants and, in particular, extremely elevated serum ferritin levels. Abnormal serum liver function tests are common, while rheumatoid factor and antinuclear antibodies are usually absent. Recent studies of the pathogenesis of the disease have suggested an important role for cytokines. Interleukin (IL)-1, IL-6 and IL-18, macrophage colony-stimulating factor, interferon-gamma and tumour necrosis factor (TNF)-alpha are all elevated in patients with AOSD. Prognosis depends on the course of the disease and tends to be more favourable when systemic symptoms predominate. Treatment includes the use of corticosteroids, often in combination with immunosuppressants (e.g. methotrexate, gold, azathioprine, leflunomide, tacrolimus, ciclosporin and cyclophosphamide) and intravenous immunoglobulin. Biological agents (e.g. anti-TNFalpha, anti-IL-1 and anti-IL-6) have been successfully used in refractory cases. Further progress has been hampered by the rarity and heterogeneity of the disease, which has not permitted the execution of randomized controlled studies.
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Affiliation(s)
- Apostolos Kontzias
- Department of Medicine, Lincoln Medical and Mental Health Center, New York, New York 10451, USA
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Zochling J, van der Heijde D, Dougados M, Braun J. Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Ann Rheum Dis 2005; 65:423-32. [PMID: 16126792 PMCID: PMC1798100 DOI: 10.1136/ard.2005.041129] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS. METHODS A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate. RESULTS Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Non-pharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients. CONCLUSION This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.
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Affiliation(s)
- J Zochling
- Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany
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Zochling J, van der Heijde D, Burgos-Vargas R, Collantes E, Davis JC, Dijkmans B, Dougados M, Géher P, Inman RD, Khan MA, Kvien TK, Leirisalo-Repo M, Olivieri I, Pavelka K, Sieper J, Stucki G, Sturrock RD, van der Linden S, Wendling D, Böhm H, van Royen BJ, Braun J. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2005; 65:442-52. [PMID: 16126791 PMCID: PMC1798102 DOI: 10.1136/ard.2005.041137] [Citation(s) in RCA: 414] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism. METHODS Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise. RESULTS The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion. CONCLUSION Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.
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Affiliation(s)
- J Zochling
- Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany
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Cronstein BN. Low-dose methotrexate: a mainstay in the treatment of rheumatoid arthritis. Pharmacol Rev 2005; 57:163-72. [PMID: 15914465 DOI: 10.1124/pr.57.2.3] [Citation(s) in RCA: 362] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Methotrexate administered weekly in low doses is a mainstay in the therapy of rheumatoid arthritis. Although originally developed as a folate antagonist for the treatment of cancer, its mechanism of action in the therapy of rheumatoid arthritis remains less clear. Several mechanisms have been proposed including inhibition of T cell proliferation via its effects on purine and pyrimidine metabolism, inhibition of transmethylation reactions required for the prevention of T cell cytotoxicity, interference with glutathione metabolism leading to alterations in recruitment of monocytes and other cells to the inflamed joint, and promotion of the release of the endogenous anti-inflammatory mediator adenosine. These mechanisms of action and the role of methotrexate in the suppression of rheumatoid arthritis are reviewed.
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Affiliation(s)
- Bruce N Cronstein
- Pathology and Pharmacology, Division of Clinical Pharmacology, Department of Medicine, NYU School of Medicine, 550 First Ave., New York, NY 10016, USA.
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Lim AYN, Gaffney K, Scott DGI. Methotrexate-induced pancytopenia: serious and under-reported? Our experience of 25 cases in 5 years. Rheumatology (Oxford) 2005; 44:1051-5. [DOI: 10.1093/rheumatology/keh685] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Siegmund B, Zeitz M. Standards of medical treatment and nutrition in Crohn's disease. Langenbecks Arch Surg 2004; 390:503-9. [PMID: 15449064 DOI: 10.1007/s00423-004-0498-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 04/07/2004] [Indexed: 12/29/2022]
Abstract
Crohn's disease is a condition of chronic inflammation potentially involving any location of the alimentary tract from mouth to anus but with a propensity for the distal small bowel and proximal large bowel. Frequent complications include stricture and fistula. Numerous extra-intestinal manifestations may also be present. The aetiology of Crohn's disease is incompletely understood, and therapy, although generally effective in alleviating the symptoms, is not curative. Due to the heterogeneity of the disease a major need for the therapeutic approach is the ability to define subgroups with distinct characteristics. However, with regard to the heterogeneity of demographic, anatomic and disease behaviour characteristics, distillation of the numerous possible phenotypes in simple categories is a formidable task. In the present review the focus will be on clinically relevant situations providing therapeutic algorithms according to international guidelines.
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Affiliation(s)
- Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
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Chan ESL, Cronstein BN. Molecular action of methotrexate in inflammatory diseases. ARTHRITIS RESEARCH 2002; 4:266-73. [PMID: 12106498 PMCID: PMC128935 DOI: 10.1186/ar419] [Citation(s) in RCA: 318] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2001] [Revised: 11/27/2001] [Accepted: 12/12/2001] [Indexed: 12/16/2022]
Abstract
Despite the recent introduction of biological response modifiers and potent new small-molecule antirheumatic drugs, the efficacy of methotrexate is nearly unsurpassed in the treatment of inflammatory arthritis. Although methotrexate was first introduced as an antiproliferative agent that inhibits the synthesis of purines and pyrimidines for the therapy of malignancies, it is now clear that many of the anti-inflammatory effects of methotrexate are mediated by adenosine. This nucleoside, acting at one or more of its receptors, is a potent endogenous anti-inflammatory mediator. In confirmation of this mechanism of action, recent studies in both animals and patients suggest that adenosine-receptor antagonists, among which is caffeine, reverse or prevent the anti-inflammatory effects of methotrexate.
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Affiliation(s)
- Edwin SL Chan
- Division of Clinical Pharmacology, NYU School of Medicine, New York, NY, USA
| | - Bruce N Cronstein
- Division of Clinical Pharmacology, NYU School of Medicine, New York, NY, USA
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