Role of methotrexate in the management of Crohn disease

Managing pediatric Crohn's disease: recent insights

INTRODUCTION

Children and adolescents with Crohn's disease present unique challenges due to extensive disease at diagnosis and the effect of bowel inflammation on growth. Historical approaches with corticosteroids and immunomodulators are far less effective than early treatment with anti-TNF biologics.

AREAS COVERED

This review covers recent literature delineating the crucial role of early anti-TNF therapy in the treatment of moderate- to- severe Crohn's disease in children and adolescents. The potential risks and benefits of concomitant immunomodulators are discussed, along with therapeutic anti-TNF drug monitoring, and reassessment by endoscopy and cross-sectional imaging to evaluate success beyond symptom control.

EXPERT OPINION

Standard of care therapy for moderate-to-severe pediatric Crohn's disease now entails precision dosing of anti-TNF therapy with periodic reassessment of bowel inflammation. The role of dietary modification continues to evolve. Current and future efforts need to be directed to elucidating ways to predict response to anti-TNF therapy and quickly changing to agents with other mechanisms of action when needed. Inordinate regulatory delays in approval of new therapies approved for adults continue to handicap pediatric clinicians and frequently limits their treatment choices, or forces them to give medications "off label." Only a concerted effort by clinicians, pharma, and regulators will improve this situation.

Methotrexate for Primary Maintenance Therapy in Mild-to-Moderate Crohn Disease in Children

OBJECTIVES

Despite limited data, methotrexate (MTX) is often used as primary maintenance therapy in pediatric Crohn disease (CD). We sought to assess the effectiveness of MTX as "initial" primary maintenance therapy in newly diagnosed mild/moderate pediatric CD and ascertain baseline predictive factors.

METHODS

Single-center 10-year retrospective review of newly diagnosed CD patients treated with MTX as primary maintenance therapy. We compared baseline characteristics of those patients with sustained response/clinical remission to those patients who escalated to anti-TNF therapy within 1 year. Pediatric Crohn Disease Activity Index (PCDAI) ≤ 10 defined remission.

RESULTS

We identified 65 patients (mean age, 11.8 years; 72 % male; mean ± SD PCDAI, 17.8 ± 10.5) who started MTX ≤4 months of diagnosis as their primary maintenance therapy. Initial therapy prior to MTX was corticosteroids (CS) (54/65), defined diet (4/65), and combination CS/diet (6/65). Oral dosing was used in 55%; mean dose was 11.4 mg/m 2 orally and 12.5 mg/m 2 subcutaneously. At 1 year, 36 of 65 (55%) were on MTX monotherapy, and of those, 32 of 36 were in clinical remission; 81% were in steroid-free remission for the year following induction. For the 36 patients on MTX at 1 year, 14 (39%) had gross mucosal healing (22% of the original cohort). Ten additional patients had mucosal improvement (37% of total healed/improved). Fifteen patients (23%) were early failures, transitioning to anti-TNF ≤4 months. Baseline PCDAI, hemoglobin, ESR, albumin, and route of administration were not predictive of outcome. MTX was well tolerated in our cohort, with only 1 patient stopping due to elevated aminotransferases. No patient required CD surgery in the 1-year follow-up.

CONCLUSIONS

MTX may have a primary maintenance role in mild/moderate CD.

Current Trends in the Treatment of Systemic Lupus Erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease in mankind. SLE's downregulation of T and B lymphocytes could cause the development of autoantibodies, which in turn attack cell surface, nuclear, and cytoplasmic molecules, creating immune complexes that harm tissues.

OBJECTIVE

The objective of the present review is to evaluate SLE's present therapeutic policies and raise consciousness about the disease.

METHODS

New therapies are rare for SLE. This is due to the complexity of the disease and its various manifestations. Three techniques are used to develop biological treatments for the illness: B-cell modulation, T-cell regulation and cytokine inhibition. This paper reviews the present trends in SLE therapy.

RESULTS

Each arm of the immune system is a prospective therapeutic development target for this disease; it involves B-cells, T-cells, interferon (IFN) and cytokines. To date, only one of these agents is been approved for use against lupus, belimumab which comes under B-cell therapy. Both the innate and the adaptive immune systems are the objectives. Currently, although there is no full SLE remedy, drug therapy can minimize organ injury and control active disease, which relies on immunosuppressants and glucocorticoids.

CONCLUSION

It is possible to access SLE treatment in the form of T-cell, B-cell and anticytokine therapies. In these therapies, antibodies and antigens interactions play a major part. Another medication for treating SLE is the non-steroidal anti-inflammatory drug such as hydroxychloroquine. Glucocorticoids (GCs) are another antiinflammatory treatment that suppresses the growth of cytokines related to inflammation and prevents the recruitment of leukocyte by reducing endothelial cell permeability.

The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update

OBJECTIVE

We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD].

METHODS

We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained.

RESULTS

We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone.

CONCLUSIONS

We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.

Methotrexate for the Treatment of Pediatric Crohn's Disease: A Systematic Review and Meta-analysis

BACKGROUND

Methotrexate (MTX) is an immunomodulator used for the treatment of pediatric inflammatory bowel disease (IBD). There are currently no RCTs that assess the treatment efficacy of methotrexate within the pediatric IBD patient population. This systematic review and meta-analysis assesses the efficacy of MTX therapy among the existing pediatric literature.

METHODS

A systematic literature search was performed using MEDLINE and the Cochrane library from inception until March 2016. Synonyms for 'pediatric', 'methotrexate' and 'IBD' were utilized as both free text and MESH search terms. The studies included contained clinical remission (CR) rates for MTX treatment of pediatric IBD patients 18 yrs old, as mono- or combination therapy. Case studies with <10 patients were excluded. Quality assessment was performed with the Newcastle-Ottawa Scale. Meta-analysis calculated pooled CR rates. A random-effects meta-analysis with forest plots was performed using R.

RESULTS

Fourteen (11 monotherapy, 1 combination therapy, 2 both; n = 886 patients) observational studies were eligible out of 202 studies. No interventional studies were identified. The pooled achieved CR rate for pediatric CD patients on monotherapy within 3-6 months was 57.7% (95% CI 48.2-66.6%), (P =0.22; I2 = 29.8%). The CR was 37.1% (95% CI 29.5-45.5%), (P = 0.20; I2 = 37.4%) for maintenance therapy at 12 months. Sub-analysis could not identify CR differences between MTX administration types, thiopurine exposure.

CONCLUSIONS

This meta-analysis demonstrated that, over 50% of pediatric Crohn's disease patients induced with methotrexate achieved clinical remission, while 12-month remission rate was only 37%. Prospective controlled interventional trials should assess treatment efficacy among patient subgroups. 10.1093/ibd/izy078_video1izy078.video15774883936001.

Therapeutic role of methotrexate in pediatric Crohn's disease

The main role of therapy in Crohn's disease (CD) is to achieve long-term clinical remission, and to allow for normal growth and development of children. The immunomodulatory drugs used for the maintenance of remission in CD include thiopurines (azathioprine and 6-mercaptopurine) and methotrexate (MTX). Development of hepatosplenic T-cell lymphoma in some patients with inflammatory bowel disease, treated with thiopurines only or in combination with anti-tumor necrosis factor agents, resulted in a growing interest in the therapeutic application of MTX in children suffering from CD. This review summarizes the literature on the therapeutic role of MTX in children with CD. MTX is often administered as a second-line immunomodulator, and 1-year clinical remission was reported in 25-69% of children with CD after excluding for the use of thiopurines. Initial data on MTX effectiveness in mucosal healing, and as a first-line immunomodulator in pediatric patients with CD, are promising. A definite conclusion, however, may only be made on the basis of additional research with a larger number of subjects.

Methotrexate in Crohn's disease: a new face for an old drug?

Methotrexate is commonly used in rheumatoid arthritis but randomised controlled trials demonstrated its efficacy also in Crohn's disease. Methotrexate, although marginally used in clinical practice, is considered an appropriate immunomodulator particularly in patients refractory or intolerant to thiopurines. Areas covered: A literature search using 'methotrexate', 'Crohn's disease' and 'Inflammatory Bowel Disease' as key words, identified randomised controlled trials, meta-analyses and observational studies. The aim of this review is to summarise and critically discuss the available evidence concerning the efficacy and safety of methotrexate in the treatment of Crohn's disease. Expert commentary: Methotrexate is effective in inducing and maintaining remission in steroid-dependent CD at a dose of 25 mg/week and 15 mg/week, respectively. Data from observational studies suggest that methotrexate may be as efficacious as thiopurines with a similar safety profile. In specific clinical settings, (patients with a history of malignancy or young Epstein-Barr Virus-seronegative patients), methotrexate compete favourably with thiopurines.

Methotrexate is an efficient therapeutic alternative in children with thiopurine-resistant Crohn's disease

OBJECTIVE

This study aimed to investigate the role of methotrexate (MTX) in the maintenance of clinical remission and mucosal healing in children with Crohn's disease (CD), in whom azathioprine (AZA) treatment failed.

MATERIALS AND METHODS

This was a retrospective, longitudinal cohort study which included all children who were diagnosed with CD during a period of 10 years and who received MTX for ≥12 months after failed AZA treatment. Remission was assessed clinically, defined by Pediatric Crohn's Disease Activity Index as a score of ≤10 and no need for the reintroduction of the remission induction therapy. In the subset of patients with sustained clinical remission, the rate of mucosal healing was endoscopically assessed. Endoscopic lesions were assessed by Simple Endoscopic Score for CD. Each patient served as his or her own historical control.

RESULTS

Of the 32 included patients, 22 (68.7%) remained in the stable clinical remission after a period of 12 months and 14 (43.8%) did not experience relapse during the whole follow up (median duration 2.9 years; range 1-4.8 years). From all patients who were in clinical remission during the entire follow up (n = 14), endoscopy was performed in eight (57%) patients and showed complete mucosal healing macroscopically (Simple Endoscopic Score for CD score of 0) and microscopically in seven out of eight (87.5%) patients.

CONCLUSION

MTX was found to be an efficient therapeutic alternative in the thiopurine-resistant patients, enabling the complete mucosal healing.

Methotrexate for the Management of Crohn's Disease in Children

OBJECTIVE

To review the literature evaluating methotrexate as a treatment option for Crohn's disease (CD) in pediatric patients.

DATA SOURCES

A search of PubMed electronic database (1966 to August 2015) and secondary resources was performed using the terms methotrexate, Crohn's, and inflammatory bowel disease. Other relevant articles cited within identified articles were also utilized.

STUDY SELECTION AND DATA EXTRACTION

Data sources were limited to English-language studies that included children less than 18 years of age. In total, 10 clinical studies met the criteria.

DATA SYNTHESIS

Awareness of the risk of hepatosplenic T-cell lymphoma associated with anti-tumor necrosis factor and thiopurine therapies has renewed interest in methotrexate to treat CD in children. According to data from 10 predominantly retrospective studies, children treated with oral or subcutaneous methotrexate once weekly had remission rates of 25% to 53% at 1 year. Adverse effects most often included nausea and vomiting, elevated liver function tests, headache, and hematological toxicity. The evidence to support methotrexate is limited by inconsistent study design and poorly described dosage regimens. It has been most frequently evaluated in patients with prior thiopurine exposure and has not been thoroughly evaluated as first-line therapy.

CONCLUSIONS

Based on results of retrospective studies, methotrexate is useful in the treatment of pediatric CD in those who fail thiopurine therapy. Remission rates with methotrexate are similar to those for thiopurine therapy, although no studies directly compare these agents. Although preliminary results are promising, prospective studies are needed to assess the use of methotrexate as initial first-line therapy in the pediatric CD population.

Methotrexate for maintaining remission in paediatric Crohn's patients with prior failure or intolerance to thiopurines: a multicenter cohort study

BACKGROUND AND AIMS

Methotrexate [MTX] is an immunomodulating drug that can be used to maintain remission in patients with Crohn's disease [CD], but data on efficacy and tolerability in children and teenagers are scarce. We evaluated the long-term efficacy and tolerability of MTX monotherapy after thiopurine therapy in paediatric CD patients.

METHODS

A multicenter cohort of paediatric MTX users who stopped thiopurines due to ineffectiveness or intolerance between 2002 and 2012 were included and followed for at least 12 months. Relapse-free use was defined as steroid and biologics-free clinical remission after the introduction of MTX, and included intentional discontinuation of successful therapy before the end of the observation period.

RESULTS

A total of 113 patients with CD in remission were followed while on MTX monotherapy, of whom 75 [66%] had failed on thiopurines and 38 [34%] had stopped thiopurines due to side effects. Median age at the introduction of MTX was 14 years [range 7 to 17], and 93% used the subcutaneous route. Kaplan-Meier analysis showed that 52% of the study cohort were still in steroid- and biologics-free remission after 12 months of MTX monotherapy, with a difference that did not reach significance between thiopurine-intolerant and thiopurine-failing patients [p = 0.21, log-rank test].

CONCLUSIONS

The findings of this cohort study suggest that MTX is an effective immunomodulator to maintain remission after stopping thiopurines. MTX maintenance should be considered before stepping up to anti-tumor necrosis factor alpha therapy. MTX is probably somewhat more effective in patients who stopped thiopurines due to side effects than in those who failed on thiopurines.

[Reccomendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of methotrexate in inflammatory bowel disease]

Methotrexate is an immunosuppressant that may be useful in several clinical scenarios in inflammatory bowel disease. In this article, we review the available evidence in Crohn's disease and ulcerative colitis and establish general recommendations for its use in clinical practice. Although the available data are limited, it is very likely that methotrexate is underused because its effectiveness is underestimated and its toxicity is overestimated. Both in induction therapy and in maintenance of remission, methotrexate is useful in Crohn's disease. When prescribed in combination with biologic agents, immunogenicity is less frequent and consequently long-term response could potentially be improved. There are few published studies, but several data suggest that methotrexate could also be useful in ulcerative colitis. Although myelotoxicity and liver toxicity are well known risks, methotrexate is a drug that is well tolerated in many patients, even in the long term.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Pediatric ulcerative colitis: a practical guide to management

Ulcerative colitis (UC) is a chronic inflammatory disorder of the gastrointestinal tract of unknown etiology that frequently presents in the pediatric population. The evaluation of pediatric UC involves excluding infection, and a colonoscopy that documents the clinical and histologic features of chronic colitis. Initial management of mild UC is typically with mesalamine therapy for induction and maintenance. Moderate UC is often initially treated with oral prednisone. Depending on disease severity and response to prednisone, maintenance options include mesalamine, mercaptopurine, azathioprine, infliximab, or adalimumab. Severe UC is typically treated with intravenous corticosteroids. Corticosteroid nonresponders should either undergo a colectomy or be treated with second-line medical rescue therapy (infliximab or calcineurin inhibitors). The severe UC patients who respond to medical rescue therapy can be maintained on infliximab or thiopurine, but 1-year remission rates for such patients are under 50 %. These medications are discussed in detail along with the initial work-up and a treatment algorithm.

Risk factors for relapse and surgery rate in children with Crohn's disease

The aim of this study was to evaluate risk factors associated with the relapse rate in the first year and the need for surgery in children with Crohn's disease (CD). Data of all children (n = 74) diagnosed with CD from January 2004 to June 2011 were retrospectively analyzed. Multivariate Cox proportional hazards regression model was used to assess whether important clinical variables at diagnosis (age, presence of perianal disease, first induction therapy, first maintenance therapy, levels of Pediatric CD Activity Index (PCDAI), C-reactive protein (CRP), and standard deviation score (SDS) for height for weight) were associated with the risk of clinical recurrence in the first year and need for surgery during follow-up. Relapse occurred in 36 (48.6 %) patients in the first year from diagnosis. The only significant parameter associated with negative risk of relapse in the first year was exclusive enteral nutrition (EEN) used as induction therapy (hazard ratio (HR) 0.469, 95 % confidence interval (CI) 0.232-0.948). EEN induced remission in 84.2 % of patients. The only risk associated with EEN treatment failure was the involvement of the upper gastrointestinal tract. During the follow-up, 25 (33.7 %) patients underwent surgery. The multivariate Cox regression model failed to recognize significant risk factor for surgery.

CONCLUSION

This study underlines the importance of early EEN in the treatment of CD; it is not only efficacious in the remission induction but could also prevent relapse in the first year.

Hepatotoxicity caused by methotrexate therapy in children with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Methotrexate (MTX) is an immunomodulator used in pediatric inflammatory bowel disease (IBD) maintenance regimens. However, MTX use is associated with liver toxicity. We aimed to systematically review and meta-analyze the incidence of hepatotoxicity with MTX use among children with IBD.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from 1946 to April 2013 for cohort studies and collected information about the study design, IBD treatment results, and hepatotoxicity. Pooled proportions of toxicity with 95% confidence interval (CI) were estimated using a random-effects model.

RESULTS

Twelve high-quality studies were included in this review. Fifty-seven of 457 patients treated with MTX developed varied degrees of abnormal liver biochemistry. The pooled proportion of patients with abnormal liver biochemistry was 10.2% (95% CI 5.4%-18.5%) across all studies included in the meta-analysis. Due to hepatotoxicity, dose reductions were required in 6.4% (95% CI 4.3%-9.5%), whereas 4.5% (95% CI 2.8%-7.2%) of patients required discontinuation.

CONCLUSIONS

Hepatotoxicity after the use of MTX among IBD patients was a relatively common event. Monitoring for hepatotoxicity is strongly recommended, as discontinuation of MTX may be necessary in a significant proportion of children.

Concomitant therapy with methotrexate and anti-TNF-α in pediatric patients with refractory crohn's colitis: a case series

BACKGROUND

Crohn's colitis refractory to anti-tumor necrosis factor alpha (TNF-α) therapy is commonly seen in tertiary care centers for pediatric inflammatory bowel disease (IBD). We report our experience in managing pediatric refractory Crohn's colitis with concomitant use of methotrexate and anti-TNF-α therapy.

METHODS

We reviewed records from 2007 to 2010 at the Mayo Clinic pediatric IBD center. We included all patients with Crohn's disease (CD) failing anti-TNF-α therapy who then received concomitant methotrexate. The primary endpoint was clinical remission, defined as inactive disease in accordance with the short pediatric CD activity index (PCDAI). The secondary endpoint was last day of follow-up.

RESULTS

Fourteen patients with CD received concomitant methotrexate and anti-TNF-α treatment (age, mean [range], 15.7 [6-20] years; standard deviation [SD], 3.4 years). Mean age at diagnosis was 12.5 years (range, 3-17 years; SD, 3.83 years). The male-to-female ratio was 10:4. All patients had moderate to severe disease activity using the short PCDAI and had predominately Crohn's colitis. Twelve patients were previously treated with thiopurines (85.7%). Seven patients (50%) were in clinical remission within an average of 6 weeks postmethotrexate induction. Five patients (35.7%) experienced adverse events including nausea and headache, yet only one discontinued therapy due to adverse events. Infection with Clostridium difficile was common, complicating therapy in four patients (28.6%).

CONCLUSIONS

Concomitant use of methotrexate and anti-TNF-α therapy is a promising option for children with refractory Crohn's colitis.

Methotrexate in the treatment of inflammatory bowel disease: an 8-year retrospective study in a Canadian pediatric IBD center

BACKGROUND

Methotrexate (MTX) is used as an alternative immunosuppressive treatment for patients with inflammatory bowel disease (IBD). The aim of the study was to evaluate effectiveness and tolerance of MTX for children with IBD.

METHODS

A retrospective study was conducted in our pediatric IBD center of all children having received MTX for the treatment of their IBD between 2000 and 2008. Remission was defined as discontinuation of steroids and Harvey-Bradshaw Index <4 for Crohn's disease (CD) patients or Pediatric Ulcerative Colitis Activity Index (PUCAI) <10 for ulcerative (UC) or indeterminate colitis (IC) patients.

RESULTS

Seventy-five patients had CD, 5 UC, and 13 IC. Mean age at diagnosis was 11 (0.6-17.4) years. Ninety patients were previously treated with purine analogs and 26 with anti-tumor necrosis factor (TNF). Among patients assessed for effectiveness of MTX (n = 79), clinical remission was observed in 29, 37, 25, and 16% of CD patients (n = 63) and 19, 25, 13, and 7% of patients with UC or IC (n = 16), respectively, 3, 6,12, and 24 months after initiation of MTX. The 1-year remission rate for CD patients was significantly higher in patients with colonic disease. Forty-six patients (49%) experienced side effects but only 13 (14%) had to discontinue treatment.

CONCLUSIONS

The long-term remission rate with MTX in our pediatric IBD population was low. However, MTX was generally well tolerated and induced and maintained remission in some patients who previously had failed a purine analog and/or anti-TNF. Prospective controlled trials are indicated to determine the place of MTX in the management of pediatric IBD.

Peripheral ulcerative keratitis in a child

Peripheral ulcerative keratitis is a destructive process involving perilimbal corneal inflammation and an overlying epithelial defect. It can be a manifestation of systemic autoimmune diseases or can be secondary to an infectious process. We present a case of a 7-year-old girl with peripheral ulcerative keratitis of unknown etiology. To the best of our knowledge, this is the first such case reported in a child.

Short-course ondansetron for the prevention of methotrexate-induced nausea in children with Crohn disease

OBJECTIVES

Methotrexate (MTX) is an effective treatment for Crohn disease (CD); however, its application may be limited by the occurrence of nausea. We assessed whether a short course of ondansetron minimized this adverse event.

PATIENTS AND METHODS

A retrospective case-control study of patients with CD who received MTX at the Children's Hospital of Eastern Ontario between 2001 and 2009 was conducted.

RESULTS

Sixty-four patients received MTX during this time period. The mean age of diagnosis was 12.0 ± 3.0 years (± standard deviation), and the mean age when MTX was initiated was 13.6 ± 2.6 years. Those receiving only 1 or 2 doses of MTX (N = 4) and stopped for reasons other than development of nausea were not included in the analysis. Fifty patients received ondansetron premedication using a 4- to 8-week tapering schedule with MTX, and only 1 patient (2.0%) developed nausea within the first 3 months of MTX. In contrast, 6 of 10 patients (60.0%, P < 0.001) not premedicated with ondansetron reported nausea following MTX within 3 months. Four of these 6 patients subsequently received ondansetron and had no further complaints. Following ondansetron discontinuation, 5 of 50 (10%) patients developed nausea with subsequent MTX injections, but responded to reinstitution of ondansetron. Some children developed anticipatory nausea (6/60, 10%) and 3 experienced nausea relief after initiating premedication with ondansetron.

CONCLUSIONS

Nausea following MTX is a common complaint in patients with CD. For most, this adverse effect may be prevented through the use of a short-course ondansetron as premedication. Ondansetron to treat MTX-induced nausea also can be successfully used but a proactive preventive strategy can be achieved.

A single-center experience with methotrexate after thiopurine therapy in pediatric Crohn disease

BACKGROUND AND AIM

Thiopurines are a common, effective means of maintaining remission in pediatric Crohn disease (CD). Methotrexate (MTX) may be considered for those intolerant of or unresponsive to thiopurines. The purpose of this study was to examine the effectiveness of MTX as maintenance therapy in patients previously treated with thiopurines.

PATIENTS AND METHODS

All of the patients at Nationwide Children's Hospital from 1998 to 2007 with an International Classification of Diseases code indicative of CD were identified. Patients with a diagnosis of CD, a history of prior thiopurine use, no current infliximab therapy, and at least 6 months of follow-up after MTX initiation were included. The primary outcome was defined as steroid-/infliximab-free remission determined by the physician global assessment at 6 and 12 months. Secondary outcomes included subsequent treatment with infliximab and/or corticosteroids, rate of discontinuation of MTX, and adverse events (AEs).

RESULTS

Twenty-seven patients (17 boys, 63%) with a mean age at diagnosis of 12.3 ± 0.7 years and mean disease duration of 1.49 ± 0.3 years were identified. Indications for MTX included nonresponse to thiopurines, AE, and poor adherence to thiopurines. At 6 and 12 months, 13 of 27 patients (48.1%) and 9 of 27 patients (33.3%), respectively, were in steroid-/infliximab-free remission. A total of 10 patients (37.0%) required infliximab therapy during the 12-month period and 5 patients discontinued MTX. Nausea was the most commonly reported AE. Transient transaminase elevation occurred in 4 patients and transient leukopenia in 2 patients.

CONCLUSIONS

MTX can be effective as maintenance therapy for patients with pediatric CD previously intolerant of or unresponsive to thiopurines; however, greater than one third of this cohort required escalation to antitumor necrosis factor therapy within 12 months following MTX initiation. MTX was well tolerated.

Methotrexate in paediatric ulcerative colitis: a retrospective survey at a single tertiary referral centre

BACKGROUND

Patients with ulcerative colitis often receive thiopurines as immunomodulators (IMs) to maintain remission and avoid corticosteroids. If unresponsive or intolerant to these agents, patients are treated with methotrexate, an antimetabolite never assessed in paediatric ulcerative colitis.

AIM

To describe the experience with methotrexate in children with ulcerative colitis.

METHODS

Thirty-two patients (median age 13.9 years) received methotrexate. Pediatric Ulcerative Colitis Activity Index (PUCAI) and use of corticosteroids were the main outcomes evaluated at baseline and at 3, 6 and 12 months.

RESULTS

Indications to methotrexate were azathioprine unresponsiveness in 18 patients, azathioprine intolerance/toxicity in 10 and spondyloarthropathy in four. Response or remission was achieved in 72%, 63% and 50% of patients at 3, 6 and 12 months respectively. Mean PUCAI were 49.5 ± 23.3 at baseline and 32.9 ± 21.9, 29.5 ± 21.8 and 29.4 ± 19.9 at 3, 6 and 12 months respectively (P: 0.03). At the beginning of methotrexate, 16 patients (50%) received corticosteroids that were discontinued in 13 of them (81%) by 6 months. At the end of the study, 11 patients (33%) needed short courses of corticosteroids for disease relapse.

CONCLUSIONS

Methotrexate may be useful in treating children with ulcerative colitis, although large, controlled trials are warranted to define better its effectiveness.

Methotrexate treatment in pediatric Crohn disease patients intolerant or resistant to purine analogues

BACKGROUND

Immunomodulatory drugs play a major role in maintaining remission and steroid sparing in children with Crohn disease. Although thiopurine agents are commonly used, unresponsiveness or intolerance to these drugs is common. The efficacy of methotrexate in maintenance of remission has been shown in adult Crohn disease; however, pediatric data are limited. Our goal was to evaluate the efficacy and safety of methotrexate in induction and maintenance of clinical remission in children with active Crohn disease who failed thiopurine treatment.

PATIENTS AND METHODS

In a retrospective multicenter study, efficacy of methotrexate in inducing and maintaining remission or response was assessed by Harvey-Bradshaw activity index, paediatric Crohn disease activity index and steroid use, in 25 children with Crohn disease, refractory or intolerant to thiopurine analogues.

RESULTS

Crohn disease was diagnosed at a mean age of 11.1 +/- 3.1 years and methotrexate was initiated at age 14.5 +/- 3.1 years. The median methotrexate dose was 12.5 mg/m2. Remission was achieved in 16 patients (64%), and response in 6 patients (24%). Out of 18 patients treated for longer than 6 months, 83% were in remission or response after 12 months of treatment. The mean duration of remission and response was 10.8 +/- 8.8 months. Steroid withdrawal was possible in 12/16 patients (75%) receiving steroids at methotrexate introduction. Adverse effects were observed in 6 patients (24%) including nausea and vomiting in 3, elevation of liver enzymes in 2 and pancreatitis in 1 patient.

CONCLUSIONS

Methotrexate is beneficial in maintaining remission and steroid-sparing treatment in children with Crohn disease following failure of thiopurine therapy.

Pediatric inflammatory bowel diseases and the risk of lymphoma: should we revise our treatment strategies?

Inflammatory bowel diseases (IBDs) are lifelong inflammatory gastrointestinal diseases starting in about one third of patients during childhood. Treatment strategies aim to control this chronic inflammatory process. Owing to recent advances in the understanding of IBD, immunosuppressive agents (mainly against TNFalpha directed) as well as biological drugs are more and more often used. This therapeutic approach clearly improved the clinical condition of the majority of patients with IBD. However, with this more aggressive treatment strategy, safety concerns clearly arise. Recently, the description of a series of a particularly severe form of T cell lymphoma in pediatric and young adult patients with IBD under immunomodulator and biological combination therapy raised the question of the risks of treatment-induced side effects or complications. As reviewed in the present article, there is a slightly increased risk of not only lymphoma development in IBD patients, potentially related to the inflammatory process, but also to the use of immunosuppressive therapies. On the basis of the literature data, were analyzed current treatment strategies for children with moderate-to-severe IBD, who are candidates to receive immunomodulator and/or biological agents potentially accelerating the risk of lymphoma development. Comparative clinical studies in IBD are still missing; however, it is prudent to think about adapting immunosuppressive therapies to the inflammatory process of the underlying disorder and if possible to reduce them to monotherapy. Alternative treatment strategies for heavy immunosuppression exist (eg, enteral nutrition in Crohn disease or colectomy in patients with ulcerative colitis) and should be considered whenever appropriate. There is a major need for comparative studies before evidence-based guidelines can be established for safest and best treatment strategies of pediatric patients with IBD.

Successful implementation of a nurse-led teaching programme to independently administer subcutaneous methotrexate in the community setting to children with Crohn's disease

BACKGROUND

Methotrexate is increasingly used as a third line immunosuppression agent in children with Crohn's disease (CD). Methotrexate is traditionally administered in the hospital setting.

AIM

To set up a nurse-led education programme to teach children/their parents to administer subcutaneous methotrexate in the community.

METHODS

All patients were given methotrexate over a 16-month period. Patient demographics including previous treatments were collected. A competency based teaching package was implemented by the inflammatory bowel disease nurse. Distances and travel times together with costings were calculated.

RESULTS

Thirty two patients (19 male; 13 female) with a median treatment age of 11.96 years (IQR 10.67-13.92) were studied. Thirty of 32 (17 children, 13 parents) were independently administering methotrexate. The median return journey distance to hospital was 23 miles (IQR 14.4-42.4) taking a median time of 52 min (IQR 41.0-73.5) for each injection. The total patient travel saving was £10,537 (average £730 per patient) and nursing time saving was £12,808 with home administration (total saving £23,345).

CONCLUSIONS

This paediatric study demonstrates that methotrexate injections can be given successfully in the majority (94%) of patients with CD independently in the community, resulting in significant time and money savings for patients and health professionals alike.

Specific considerations in the treatment of pediatric inflammatory bowel disease

Inflammatory bowel disease is one of the most prevalent chronic inflammatory disorders and commonly presents during childhood or adolescence. Occurring during a critical period of growth and development, pediatric Crohn's disease and ulcerative colitis require special consideration. Children often experience growth failure, malnutrition, pubertal delay and bone demineralization. Medical treatment must be optimized to promote clinical improvement and reverse growth failure with minimal toxicity. In addition to pharmacologic and surgical interventions, nutritional therapies play a vital role in the management of pediatric inflammatory bowel disease. This review will outline the epidemiology and clinical complications that are unique to pediatric inflammatory bowel disease, current trends, and recent advances in nutritional and pharmacologic treatment, and projected future therapeutic direction.

Current treatment of inflammatory bowel disease in children

Children with inflammatory bowel disease present formidable therapeutic challenges. As both Crohn's disease and ulcerative colitis remain medically incurable conditions associated with potentially significant morbidity, the focus of treatment must be to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications and minimize the potential psychological effects of these chronic illnesses. This review focuses on the evidence supporting the treatments currently used in children with inflammatory bowel disease, and suggests potential treatment algorithms for particular clinical circumstances.

Methotrexate following unsuccessful thiopurine therapy in pediatric Crohn's disease

BACKGROUND

The thiopurines, azathioprine and 6-mercaptopurine, are traditional first-line immunomodulatory agents in adult and pediatric Crohn's disease, but the comparative efficacy and safety of methotrexate have seldom been examined. We report outcomes with methotrexate treatment in pediatric patients previously refractory to or intolerant of thiopurines.

METHODS

In a four-center, retrospective cohort study, efficacy of methotrexate in maintaining remission was assessed by PCDAI measurements, steroid use, and height velocity. Patients served as their own historical controls. Multivariable analysis controlled for route of methotrexate administration, reason for thiopurine discontinuation, baseline disease activity, and disease duration.

RESULTS

Forty-two percent of 60 children treated with methotrexate were in clinical remission without steroids at both 6 and 12 months. A strong steroid sparing effect was observed compared with the year prior to methotrexate (P<0.001). Success rates were similar in previously thiopurine-intolerant and refractory patients. Height velocity increased from -1.9 SDS to -0.14 SDS (P=0.004) in the year following therapy. In a median 3-yr follow-up, a third of the patients did not require escalation of therapy; the others required step-up therapy with infliximab or surgery. Eight children (13%) stopped methotrexate due to adverse events, including, most commonly, elevated liver enzymes, and one serious episode of sepsis.

CONCLUSION

Methotrexate appears effective in maintaining remission in pediatric Crohn's disease, when thiopurines have failed. Consideration should be given to its use earlier in pediatric treatment algorithms.