1
|
Kameda H, Yamaoka K, Yamanishi Y, Tada M, Koike R, Nakajima A, Fusama M, Fujii T. Japan College of Rheumatology guidance for the use of methotrexate in patients with rheumatoid arthritis: Secondary publication. Mod Rheumatol 2023; 34:1-10. [PMID: 37819199 DOI: 10.1093/mr/road098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/17/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
Methotrexate (MTX), the anchor drug in the current treatment strategy for rheumatoid arthritis (RA), was first approved for the treatment of RA in Japan in 1999 at a recommended dose of 6-8 mg/week. The approved maximum dose of MTX has been 16 mg/week since February 2011 when MTX was approved as a first-line drug in the treatment of RA. Recent evidence of MTX-polyglutamate concentration in the red blood cells of Japanese patients with RA justifies the current daily use of MTX in Japan. Additionally, after a nationwide clinical trial, a subcutaneous MTX injection formula (7.5-15 mg/week) was approved for RA treatment in September 2022. Therefore, in March 2023, a subcommittee of the Japan College of Rheumatology updated the guidance (formerly 'guidelines') for the use of MTX in Japanese patients with RA. This article, an abridged English translation summarizing the 2023 update of the Japan College of Rheumatology guidance for the use of MTX and management of patients with RA, will be helpful to both Japanese and global rheumatology communities.
Collapse
Affiliation(s)
- Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | | | - Masahiro Tada
- Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Ryuji Koike
- Health Science Research and Development Center of Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
- Department of Rheumatology, Mie University Graduate School of Medicine, Mie, Japan
| | - Mie Fusama
- School of Nursing, Takarazuka University, Osaka, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| |
Collapse
|
2
|
Harty T, O'Shaughnessy M, Harney S. Therapeutics in rheumatology and the kidney. Rheumatology (Oxford) 2023; 62:1009-1020. [PMID: 35951751 DOI: 10.1093/rheumatology/keac460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/08/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
The field of rheumatology has advanced significantly in recent years to provide rheumatologists with an extensive array of medications to combat rheumatic joint conditions. In contrast to an older era, when NSAIDs and other nephrotoxic agents were the mainstay of treatment, modern DMARDs vary considerably in their nephrotoxic potential and their use is not always precluded in populations with pre-existing chronic kidney disease (CKD). This review will explore in detail the safety and efficacy profiles of medications used to treat rheumatologic disease, specifically in the setting of CKD. Specifically, we discuss both traditional agents used, i.e. NSAIDs, CSs and conventional synthetic DMARDs, as well as novel biologic DMARDs and targeted synthetic DMARDs. Anti-gout prescribing in CKD is also reviewed. We aim to provide practical guidance to rheumatologists, nephrologists and general physicians when prescribing these medications in the setting of CKD.
Collapse
Affiliation(s)
| | | | - Sinead Harney
- School of Medicine, University College Cork.,Department of Rheumatology, Cork University Hospital, Cork, Ireland
| |
Collapse
|
3
|
Ghannoum M, Roberts DM, Goldfarb DS, Heldrup J, Anseeuw K, Galvao TF, Nolin TD, Hoffman RS, Lavergne V, Meyers P, Gosselin S, Botnaru T, Mardini K, Wood DM. Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2022; 17:602-622. [PMID: 35236714 PMCID: PMC8993465 DOI: 10.2215/cjn.08030621] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m2]: 91 patients; low-dose [≤0.5 g/m2]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: (1) suggested against extracorporeal treatments when glucarpidase is not administered; (2) recommended against extracorporeal treatments when glucarpidase is administered; and (3) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: (1) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; (2) extracorporeal treatments remove folinic acid; (3) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and (4) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.
Collapse
Affiliation(s)
- Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada.,Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia; and St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Goldfarb
- Nephrology Division, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | - Tais F Galvao
- School of Pharmaceutical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, Pennsylvania
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Paul Meyers
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, McGill University Emergency Department, Montreal, Quebec and Centre Antipoison du Québec, Quebec, Canada
| | - Tudor Botnaru
- Emergency Department, Lakeshore General Hospital, CIUSSS de l'Ouest-de-l'lle-de-Montreal, McGill University, Montreal, Quebec, Canada
| | - Karine Mardini
- Pharmacy Department, Verdun Hospital, CIUSSS du Sud-Ouest-de-l'ïle-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
| | | |
Collapse
|
4
|
Hajar T, Latour EJ, Haynes D, Topham C, Hill EE, Simpson EL, Greiling TM. Low-dose methotrexate in dermatology: the utility of serological monitoring in a real-world cohort. J DERMATOL TREAT 2021; 33:2161-2167. [PMID: 34148493 DOI: 10.1080/09546634.2021.1937476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
When prescribing low-dose methotrexate, frequent serological testing is recommended in the dermatologic literature, although much of the supporting data is extrapolated from non-dermatologic conditions. We performed a retrospective cohort study to determine the cumulative incidence and timing of low-dose methotrexate-associated serological abnormalities over the first year of therapy, in a pragmatic cohort of patients with dermatologic compared to non-dermatologic diagnoses. Laboratory values recorded included white blood cell count, hemoglobin, platelet count, estimated glomerular filtration rate, alanine aminotransferase, and aspartate aminotransferase. Among 1376 patients, there were no cases of methotrexate-associated grade 4/very severe lab abnormality or fatality. Baseline risk factors associated with moderate-to-severe lab abnormalities included non-dermatologic diagnoses, low hemoglobin, low estimated glomerular filtration rate, and elevated transaminases. The incidence of moderate-to-severe lab abnormalities was 4.4% among all patients, 3.1% among patients with dermatologic diagnoses, and 2.3% among patients with normal baseline lab values. Lab abnormalities led to discontinuation of therapy in 0.8% of patients. Serious changes did not occur in the first two weeks of therapy. We conclude that the cumulative incidence of low-dose methotrexate-associated lab abnormality was lower in patients with dermatologic diagnoses or normal baseline testing and these factors may be used to adjust monitoring practices.
Collapse
Affiliation(s)
- Tamar Hajar
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.,Department of Dermatology,University of Colorado, Denver, CO, USA
| | - Emile J Latour
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Dylan Haynes
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Christina Topham
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.,Department of Dermatology, University of Utah, Salt Lake City, UT, USA
| | - Emma E Hill
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Teri M Greiling
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| |
Collapse
|
5
|
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.
Collapse
Affiliation(s)
| | - Winifred Baah
- Korle Bu Teaching Hospital, Department of Medicine and Therapeutics, Accra, Ghana
| |
Collapse
|
6
|
AKDAĞ İ, ERSOY A. Development of pancytopenia after single low-dose methotrexate therapy in patients with chronic kidney disease: a review of the literature. TURKISH JOURNAL OF INTERNAL MEDICINE 2020. [DOI: 10.46310/tjim.766086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
7
|
Cytopénies secondaires au méthotrexate à faible dose. Ann Dermatol Venereol 2020; 147:252-253. [DOI: 10.1016/j.annder.2020.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
8
|
Mazaud C, Fardet L. Daily practices regarding safety monitoring of low-dose methotrexate and comparison to guidelines: A population-based cohort study. Therapie 2019; 76:425-433. [PMID: 32354461 DOI: 10.1016/j.therap.2019.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/28/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe daily practices regarding safety monitoring of methotrexate prescribed at low-(i.e.≤30mg/week). To identify determinants of these practices. To assess association between monitoring and early methotrexate discontinuation. METHODS Population-based cohort study using the French claims database échantillongénéralistedebénéficiaires (EGB) over the period 2009-2015. Incident methotrexate users were included. The pre-treatment and post-treatment monitoring prescribed to these patients was analyzed. Determinants of monitoring were identified using a logistic regression model. Association between monitoring and early methotrexate discontinuation was assessed using Cox proportional-hazards model. RESULTS During the study period, 615924 individuals had data in the EGB and 2472 (0.40%) were incident methotrexate users (63.3% women; mean age: 54.7±17.8 years; mean weekly dosage: 13.0±5.3mg). Among these incident users, only 50-70% had an albumin testing (67.0%); HIV (49.7%), hepatitis B (54.8%) or C (55.0%) serology; or chest X-ray (57.4%) within the year before initiating methotrexate. Only 65.7% had a least one CBC, transaminase and urea-creatinine testing combined within the three months before initiation. During the first three months of exposure, the median number of CBC, transaminase and urea-creatinine testing was 2 [1-4], 2 [1-4], and 2 [1-3], respectively. The monitoring modalities depend more on prescriber characteristics than on patient or treatment characteristics. There was a significant positive association between frequency of monitoring during exposure and early methotrexate discontinuation. CONCLUSION Monitoring of patients prescribed low-dose methotrexate is much less frequent than recommended. Frequent monitoring is associated with early methotrexate discontinuation.
Collapse
Affiliation(s)
- Canelle Mazaud
- Service de dermatologie, hôpital Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Laurence Fardet
- Service de dermatologie, hôpital Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; EA 7379, EpiDermE, université Paris Est Créteil (UPEC), 94010 Créteil, France.
| |
Collapse
|
9
|
Dalkilic E, Coskun BN, Yağız B, Tufan AN, Ermurat S, Pehlivan Y. Methotrexate intoxication: Beyond the adverse events. Int J Rheum Dis 2018; 21:1557-1562. [PMID: 30146743 DOI: 10.1111/1756-185x.13339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Methotrexate (MTX) is the first-line disease-modifying antirheumatic drug in rheumatoid arthritis (RA). However, this anchor may cause some side effects that may range from nausea to mortality. The clinical features of MTX toxicity are under-researched. In this study, we aimed to find out the potential predisposing factors and outcomes of the MTX toxicity (n = 31). METHODS The data were collected from 31 patients whose ages ranged from 25 to 81 years, who were suffering from immune-mediated inflammatory diseases and major MTX-related toxicity. RESULTS Out of 31 patients, six (19.4%) used MTX every day, and 13 (41.9%) patients had renal insufficiency who were admitted to the hospital because of mucositis (90.3%) and fever (71%). While using MTX, 27 patients (87.1%) were discharged after the treatment and four patients (12.9%) died. CONCLUSIONS Although MTX has high efficacy for the toxicity ratio, wrong use and dosage of MTX may be harmful to patients. Thus, patients should be informed about the proper use of MTX.
Collapse
Affiliation(s)
- Ediz Dalkilic
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Belkıs Nihan Coskun
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Burcu Yağız
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Ayşe Nur Tufan
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Selime Ermurat
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Yavuz Pehlivan
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| |
Collapse
|
10
|
Kameda H, Fujii T, Nakajima A, Koike R, Sagawa A, Kanbe K, Tomita T, Harigai M, Suzuki Y. Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis. Mod Rheumatol 2018; 29:31-40. [DOI: 10.1080/14397595.2018.1472358] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Hideto Kameda
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Center for Rheumatic Diseases, Mie University Graduate School of Medicine, Mie, Japan
| | - Ryuji Koike
- Medical Innovation Promotion Center, Clinical Research Center of Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Sagawa
- Sagawa Akira Rheumatology Clinic, Hokkaido, Japan
| | - Katsuaki Kanbe
- Department of Kuranomachi Community Medicine, Regional Clinical Education Center, Jichi Medical University, Tochigi, Japan
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Division of Rheumatology, Tokai University School of Medicine, Kanagawa, Japan
| | | |
Collapse
|
11
|
Mazaud C, Fardet L. Relative risk of and determinants for adverse events of methotrexate prescribed at a low dose: a systematic review and meta-analysis of randomized placebo-controlled trials. Br J Dermatol 2017; 177:978-986. [PMID: 28182264 DOI: 10.1111/bjd.15377] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 12/13/2022]
Abstract
Low-dose (i.e. ≤ 30 mg per week) methotrexate is widely prescribed by dermatologists. However, there is limited evidence-based information regarding the relative risk of and determinants for adverse events associated with this treatment. The aims of this review were to assess the relative risk of and the determinants for adverse events associated with low-dose methotrexate exposure. A systematic review was undertaken using the MEDLINE, Embase and CENTRAL databases. Randomized controlled trials comparing low-dose methotrexate with placebo were eligible. Random effect meta-analyses were conducted to assess the risk ratios (RRs) of adverse events associated with methotrexate exposure. Subgroup analyses and random effect meta-regressions were performed to examine the determinants of adverse events. In total, 68 trials (6938 participants) were included. Compared with placebo, low-dose methotrexate slightly increased the risk of adverse events (mean number per individual: 1·78 ± 2·00 in the methotrexate group, 1·53 ± 1·89 in the placebo group; P < 0·001), including nausea/vomiting, elevated transaminase levels, mucosal ulcerations, leucopenia, thrombopenia and infectious events, but not the risk of serious adverse events or death. Low-dose methotrexate also increased the number of withdrawals from studies because of adverse events [RR 1·32 (1·13-1·53)]. The concomitant prescription of folic/folinic acid was associated with a significant lower risk of any adverse events, and methotrexate prescribed orally was associated with a higher risk of abdominal pain than when prescribed subcutaneously or by intramuscular injection. On the other hand, the risk of adverse events did not increase with the weekly dose or with duration of exposure. Similar studies comparing methotrexate with other systemic/biological treatments are needed.
Collapse
Affiliation(s)
- C Mazaud
- Service de Dermatologie, Hôpital Henri Mondor, Créteil, France
| | - L Fardet
- Service de Dermatologie, Hôpital Henri Mondor, Créteil, France.,EA 7379, EpiDermE, UPEC Université Paris Est Créteil, Créteil, France
| |
Collapse
|
12
|
Abstract
The majority of rheumatic diseases are chronic and require long-term use of disease-modifying agents to confer the best chance of controlling the disease. A significant proportion of these drugs have a risk, albeit small, of potentially serious side effects, such as neutropenia; therefore, there has been an understandable concern over the use of potentially toxic rheumatic drugs in the elderly. Factors that may contribute to this concern include age, pre-existing co-morbidities, polypharmacy, difficulty in monitoring side effects, and patient perception. The risk of using such medication needs to be balanced with their benefits in controlling chronic disease. This review discusses how rheumatic disease and anti-rheumatic medication are associated with neutropenia in an older age group. Of the rheumatic diseases, we give special focus to rheumatoid arthritis and the use of methotrexate, as well as touching on management considerations in neutropenia.
Collapse
|
13
|
Ajmani S, Preet Singh Y, Prasad S, Chowdhury A, Aggarwal A, Lawrence A, Misra R, Mishra R, Agarwal V. Methotrexate-induced pancytopenia: a case series of 46 patients. Int J Rheum Dis 2017; 20:846-851. [PMID: 28261918 DOI: 10.1111/1756-185x.13004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIM Methotrexate (MTX) has the potential to cause serious adverse reactions and even mortality. We analyzed the predisposing factors and outcome in patients with MTX-induced pancytopenia admitted into our unit from 1996 to 2015. METHODS Patients were identified by departmental database search. Pancytopenia was defined as white blood cell count (WBC) < 3500 cells/mm3 , hemoglobin (Hb) < 11 g/dL and platelet count < 150 000 cells/mm3 . Severe pancytopenia was defined as WBC < 2000 cells/mm3 , Hb < 10 g/dL and platelet count < 50 000 cells/mm3 . RESULTS Forty-six patients were included in the study (female = 35). Twenty-four had been under the care of either primary care physicians or orthopedic surgeons and presented to us with pancytopenia. Sixteen patients had severe pancytopenia. Disease distribution was as follows: rheumatoid arthritis 33, psoriasis eight, systemic sclerosis two and others three. The median dose of MTX was 10 mg/week and median duration of treatment was 11 months. The median cumulative dose was 750 mg. Symptoms at presentation included: oral mucositis (n = 37); fever (n = 24); diarrhea (n = 12), bleeding gums (n = 5) and purpura (n = 3). The potential risk factors were: hypoalbuminemia (n = 23), renal insufficiency (n = 14), dosing errors (n = 13) and non-supplementation of folates (n = 7). Thirteen patients died. WBC at admission was found to determine survival (P < 0.05). CONCLUSION In patients on MTX, oral mucositis and fever can herald pancytopenia. MTX-induced pancytopenia is associated with high mortality. WBC at admission is the most important prognostic factor. There is need for increased awareness among physicians to minimize prescribing errors. A national guideline on monitoring of patients on MTX is desirable.
Collapse
Affiliation(s)
- Sajal Ajmani
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Yogesh Preet Singh
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Shiva Prasad
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Abhra Chowdhury
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Able Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ramnath Misra
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Richa Mishra
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
14
|
Mortensen KL, Krogh TP, Jensen-Fangel S, Hauge EM. Severe acute pancytopaenia in a patient with rheumatoid arthritis complicated by fatal invasive pulmonary aspergillosis. Scand J Rheumatol 2016; 46:249-250. [PMID: 27575284 DOI: 10.1080/03009742.2016.1209553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- K L Mortensen
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark.,b Department of Medicine , Randers Regional Hospital , Randers , Denmark
| | - T P Krogh
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - S Jensen-Fangel
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark
| | - E M Hauge
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark.,d Department of Clinical Medicine , Aarhus University , Aarhus , Denmark
| |
Collapse
|
15
|
Factors Associated with Myelosuppression Related to Low-Dose Methotrexate Therapy for Inflammatory Rheumatic Diseases. PLoS One 2016; 11:e0154744. [PMID: 27128679 PMCID: PMC4851368 DOI: 10.1371/journal.pone.0154744] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/18/2016] [Indexed: 12/12/2022] Open
Abstract
Objective Severe myelosuppression is a serious concern in the management of rheumatic disease patients receiving methotrexate (MTX) therapy. This study was intended to explore factors associated with the development of MTX-related myelosuppression and its disease severity. Methods We retrospectively examined a total of 40 cases of MTX-related myelosuppression that had been filed in the registries of participating rheumatology and hematology divisions. Data before onset were compared with those of 120 controls matched for age and sex. Cytopenia was graded according to the National Cancer Institute criteria for adverse events. Data before and at onset were compared between the severe and non-severe groups. Results Non-use of folic acid supplements, concurrent medications, and low renal function were significantly associated with the development of myelosuppression (p < 0.001, p < 0.001, and p = 0.002, respectively). In addition, significantly lower MTX dosages, higher blood cell counts, and lower hemoglobin levels were seen in the myelosuppression group (p < 0.001). No patients exhibited leukocytopenia, neutropenia, or thrombocytopenia in routine blood monitoring taken within the past month. One-fourth developed myelosuppression within the first two months (an early-onset period). Myelosuppression was severe in approximately 40% of patients. Hypoalbuminemia and non-use of folic acid supplements were significantly associated with the severity of pancytopenia (p = 0.001 and 0.008, respectively). Besides these two factors, early onset and the use of lower doses of MTX were significantly associated with the severity of neutropenia (p = 0.003, 0.007, 0.003, and 0.002, respectively). Conclusions Myelosuppression can occur abruptly at any time during low-dose MTX therapy, but severe neutropenia is more likely to occur in the early-onset period of this therapy. Contrary to our expectations, disease severity was not dependent on MTX doses. Serum albumin levels and folic acid supplementation are the important factors affecting the severity of MTX-related pancytopenia and neutropenia.
Collapse
|
16
|
Ling T, Clayton T, Crawley J, Exton L, Goulden V, Ibbotson S, McKenna K, Mohd Mustapa M, Rhodes L, Sarkany R, Dawe R, McHenry P, Hughes J, Griffiths M, McDonagh A, Buckley D, Nasr I, Swale V, Duarte Williamson C, Levell N, Leslie T, Mallon E, Wakelin S, Hunasehally P, Cork M, Ungureanu S, Donnelly J, Towers K, Saunders C, Davis R, Brain A, Exton L, Mohd Mustapa M. British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen–ultraviolet A therapy 2015. Br J Dermatol 2016; 174:24-55. [DOI: 10.1111/bjd.14317] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2015] [Indexed: 01/28/2023]
Affiliation(s)
- T.C. Ling
- Dermatology Centre Faculty of Medical and Human Sciences Salford Royal NHS Foundation Trust Salford Manchester M6 8HD U.K
| | - T.H. Clayton
- Dermatology Centre Faculty of Medical and Human Sciences Salford Royal NHS Foundation Trust Salford Manchester M6 8HD U.K
| | - J. Crawley
- Department of Dermatology University College Hospital 235 Euston Road London NW1 2BU U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - V. Goulden
- Department of Dermatology Leeds Teaching Hospitals NHS Trust Leeds LS7 4SA U.K
| | - S. Ibbotson
- Department of Dermatology Ninewells Hospital and Medical School University of Dundee Dundee DD1 9SY U.K
| | - K. McKenna
- Department of Dermatology Belfast City Hospital Belfast BT9 7AB U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - L.E. Rhodes
- Dermatology Research Centre Faculty of Medical and Human Sciences Salford Royal NHS Foundation Trust Salford Manchester M6 8HD U.K
| | - R. Sarkany
- Department of Dermatology University College Hospital 235 Euston Road London NW1 2BU U.K
| | - R.S. Dawe
- Department of Dermatology Ninewells Hospital and Medical School University of Dundee Dundee DD1 9SY U.K
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Goodman SM. Optimizing Perioperative Outcomes for Older Patients with Rheumatoid Arthritis Undergoing Arthroplasty: Emphasis on Medication Management. Drugs Aging 2015; 32:361-9. [DOI: 10.1007/s40266-015-0262-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
18
|
Gürcan H, Razzaque Ahmed A. Analysis of current data on the use of methotrexate in the treatment of pemphigus and pemphigoid. Br J Dermatol 2009; 161:723-31. [DOI: 10.1111/j.1365-2133.2009.09246.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
19
|
Thonhofer R, Kriessmayr M, Thonhofer U, Wipfler E, Uitz E, Bahadori B, Eder S. Rheumatoid arthritis patients with therapy‐induced myelodysplastic syndrome present with long‐term remission after recovery. Scand J Rheumatol 2009; 36:149-51. [PMID: 17476623 DOI: 10.1080/03009740600844506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
20
|
Hocaoglu N, Atilla R, Onen F, Tuncok Y. Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy. Hum Exp Toxicol 2008; 27:585-9. [DOI: 10.1177/0960327108094507] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancytopenia is a rare but serious adverse effect of low-dose methotrexate (MTX) sodium therapy, and this case report describes a very early-onset of pancytopenia and cutaneous lesions after three days of ingestion. A 64-year-old man was presented to Emergency Department with weakness, fever, poor appetite, nausea, and vomiting after he had had accidentally ingested MTX tablets (2.5 mg) twice a day for the last three days. On initial examination, several painful lesions in his oral mucosa and a cutaneous ulceration on his right foot were also observed. He had severe pancytopenia, poor kidney functions, and abnormal coagulation parameters. The blood level of MTX was found to be within therapeutic range. He was treated with leucovorine, intravenous antibiotics, and appropriate blood transfusions; he was discharged from hospital without any sequela. Pancytopenia associated with low-dose (cumulative dose of 15 mg in 3 days) MTX therapy had not been reported previously. The Naranjo probability scale showed pancytopenia and skin ulcer associated with low-dose MTX therapy as probable adverse reactions. Risk factors for pancytopenia such as renal insufficiency, hypoalbuminemia, low folate levels, concomitant infections, concomitant use of drugs, and folate supplementation were not identified in our patient. Although pancytopenia associated with low-dose MTX therapy is not expected as early as 3 days after initiation of the therapy, physicians should also be aware of this life threatening adverse effect during the very first days of MTX therapy for rheumatoid arthritis patients.
Collapse
Affiliation(s)
- N Hocaoglu
- Staff of Pharmacology, Department of Pharmacology, Dokuz Eylul University, School of Medicine, Izmir, Turkey
| | - R Atilla
- Department of Emergency Medicine, Dokuz Eylul University, School of Medicine, Izmir, Turkey
| | - F Onen
- Department of Internal Medicine, Division of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Y Tuncok
- Staff of Pharmacology, Department of Pharmacology, Dokuz Eylul University, School of Medicine, Izmir, Turkey
| |
Collapse
|
21
|
Yamauchi PS, Lowe NJ. Etanercept therapy allows the tapering of methotrexate and sustained clinical responses in patients with moderate to severe psoriasis. Int J Dermatol 2008; 47:202-4. [DOI: 10.1111/j.1365-4632.2008.03419.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Mahr AD, Jover JA, Spiera RF, Hernández-García C, Fernández-Gutiérrez B, Lavalley MP, Merkel PA. Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis. ACTA ACUST UNITED AC 2007; 56:2789-97. [PMID: 17665429 DOI: 10.1002/art.22754] [Citation(s) in RCA: 361] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To reevaluate the efficacy and safety of adjunctive low-dose methotrexate (MTX) in giant cell arteritis (GCA). METHODS An individual patient data meta-analysis of 3 randomized placebo-controlled trials in patients with newly diagnosed GCA was performed. Treatment consisted of initial high-dose corticosteroids and randomly assigned oral MTX therapy (7.5-15 mg/week) or placebo. Time-to-event outcomes were compared between groups using Cox proportional hazards models stratified by trial, and continuous outcomes were compared by calculating weighted mean differences. RESULTS The combined data set comprised 161 patients, of whom 84 received MTX and 77 received placebo. The mean duration of followup was 54.7 weeks (SD 39.2 weeks). Hazard ratios (HRs) for a first and second relapse of GCA were 0.65 (P = 0.04) and 0.49 (P = 0.02), respectively, in patients receiving MTX as compared with patients receiving placebo. Accordingly, a predicted 3.6 individuals (95% confidence interval [95% CI] 2.2-56.8) and 4.7 individuals (95% CI 3.3-21.9) need to be treated with MTX to prevent the occurrence of one first or one second relapse, respectively, up to 48 weeks. Use of MTX resulted in a reduction in the corticosteroid cumulative dose by 842 mg within 48 weeks (P < 0.001). Moreover, MTX treatment was associated with a higher probability of achieving sustained discontinuation of corticosteroids for > or =24 weeks (HR 2.84, P = 0.001). Dropout rates and occurrence of adverse events did not differ between treatment groups. CONCLUSION In GCA, adjunctive treatment with MTX lowers the risk of relapse and reduces exposure to corticosteroids. These findings indicate that MTX could be considered as a therapeutic option in addition to standard-of-care treatment with corticosteroids for patients with GCA.
Collapse
Affiliation(s)
- Alfred D Mahr
- Vasculitis Center, Boston University School of Medicine, 75 Albany Street, Boston, MA 02118, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Serraj K, Federici L, Maloisel F, Alt M, Andrès E. Pancytopénie sous méthotrexate à faibles doses: étude de cinq observations et revue de la littérature. Rev Med Interne 2007; 28:584-8. [PMID: 17451848 DOI: 10.1016/j.revmed.2007.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 03/14/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study is to report personal experience of pancytopenia related to low-dose methotrexate and to review the literature. METHODS We included retrospectively all cases of pancytopenia related to low-dose methotrexate (<25 mg/week), followed between January 1997 and December 2006, in the university hospital of Strasbourg, France. RESULTS Five women, mean age 75.6 years, were included in the present study. Clinical manifestations included: symptomatic anemia (n=4), infection (n=3) and hemorrhagic manifestations (n=2); one patient had no feature. Mean hemoglobin concentration was 8,8 g/dl; mean white cell and platelet counts were 1,500 /mm(3) and 16,000 /mm(3), respectively. Potential risk factors were identified in all patients: renal failure and low serum albumin levels (n=5), anti-inflammatory drug intake (n=2), folate deficiency (n=4) and cobalamin deficiency (n=1). One patient died of septic and hemorrhagic cerebral complications. CONCLUSION Pancytopenia related to tow-dose methotrexate is a rare but life-threatening disorder. Search and prevention of potential risk factors are required in all patients; determination of MTHFR genotype may be of several interests as folate supplementation.
Collapse
Affiliation(s)
- K Serraj
- Service de médecine interne, diabète et maladies métaboliques, clinique médicale B du CHU de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | | | | | | | | |
Collapse
|
24
|
Preet Singh Y, Aggarwal A, Misra R, Agarwal V. Low-dose methotrexate-induced pancytopenia. Clin Rheumatol 2006; 26:84-7. [PMID: 16636937 DOI: 10.1007/s10067-006-0301-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Revised: 04/02/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
Methotrexate (MTX) has gained wide acceptance among both patients and rheumatologists due to its efficacy and safe therapeutic window in a variety of inflammatory rheumatological disorders. However, it has the potential to cause serious, life-threatening complications and even mortality. In the present series, we have reviewed our data of five patients who developed serious pancytopenia after the use of MTX, including one who died. Two of these resulted from prescription errors by primary care physicians. The clinical, laboratory, and outcome profile of all five cases are discussed with a brief review of the literature about MTX-induced pancytopenia. There is an urgent need to increase awareness in primary care physicians, patients, and pharmacists toward informed prescribing, dispensing, and monitoring of MTX to prevent such mishaps in the future.
Collapse
Affiliation(s)
- Yogesh Preet Singh
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | |
Collapse
|