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Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 291] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
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Cohen JA, Calabresi PA, Chakraborty S, Edwards KR, Eickenhorst T, Felton WL, Fisher E, Fox RJ, Goodman AD, Hara-Cleaver C, Hutton GJ, Imrey PB, Ivancic DM, Mandell BF, Perryman JE, Scott TF, Skaramagas TT, Zhang H. Avonex Combination Trial in relapsing—remitting MS: rationale, design and baseline data. Mult Scler 2008; 14:370-82. [DOI: 10.1177/1352458507083189] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To review the rationale, design and baseline data of the Avonex Combination Trial (ACT), an investigator-run study of intramuscular interferon beta-1a (IM IFNβ-1a) combined with methotrexate (MTX) and/or IV methylprednisolone (IVMP) in relapsing—remitting multiple sclerosis (RRMS) patients with continued disease activity on IM IFNβ-1a monotherapy. Methods Eligibility criteria included RRMS, Expanded Disability Status Scale score 0—5.5, and ≥1 relapse or gadolinium-enhancing MRI lesion in the prior year while on IM IFNβ-1a monotherapy. Subjects continued IFNβ-1a 30 mcg IM weekly and were randomized in a 2 × 2 factorial design to adjunctive weekly placebo or MTX 20 mg PO, with or without IVMP 1000 mg/day for three days every other month. ACT was industry-supported, and collaboratively designed and governed by an Investigator Steering Committee with independent Advisory and Data Safety Monitoring Committees. Study operations, MRI analysis and aggregated data were managed by the Cleveland Clinic MS Academic Coordinating Center. Results In total 313 subjects were enrolled with clinical and MRI characteristics typical of RRMS. Most subjects (86.9%) qualified with a clinical relapse, with or without an enhancing MRI lesion, in the preceding year. At baseline, 21.4% had enhancing lesions, and 5.1% had anti-IFNβ neutralizing antibodies. ACT's management and operational structures functioned well. Conclusion This study provides an innovative model for academic—industry collaborative MS research and will enhance understanding of the utility of combination therapy for RRMS patients with continued disease activity on an established first-line treatment. Multiple Sclerosis 2008; 14: 370—382. http://msj.sagepub.com
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Affiliation(s)
- JA Cohen
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA,
| | - PA Calabresi
- Department of Neurology, Johns Hopkins, Baltimore, MD 21287, USA
| | - S. Chakraborty
- Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - KR Edwards
- MS Center of Southern Vermont, Bennington, VT 05201, USA
| | - T. Eickenhorst
- Medical Affairs, Biogen Idec, Inc., Cambridge, MA 02142, USA
| | - WL Felton
- Department of Neurology, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA
| | - E. Fisher
- Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - RJ Fox
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - AD Goodman
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA
| | - C. Hara-Cleaver
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - GJ Hutton
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - PB Imrey
- Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - DM Ivancic
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - BF Mandell
- Department of Rheumatic and Immunologic Disease, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - JE Perryman
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - TF Scott
- Drexel College of Medicine, Pittsburgh, PA 15212, USA
| | - TT Skaramagas
- Mellen Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - H. Zhang
- Medical Affairs, Biogen Idec, Inc., Cambridge, MA 02142, USA
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Abstract
Low dose methotrexate (MTX) can cause numerous gastrointestinal, pulmonary, central nervous system, and hematologic toxicities. Risk factors include folate deficiency, decreased renal function, older age, increased mean corpuscular volume or concomitant use of trimethoprim-sulphamethoxazole, probenecid, or nonsteroidal antiinflammatory drugs (NSAIDs). We describe a case of isolated thrombocytopenia after a single oral dose of MTX in a 36-year-old woman with sarcoidosis. She had rheumatoid arthritis and her only other medications included NSAIDs. One week after her first oral dose of 7.5 mg MTX, diffuse petechiae developed on her chest, abdomen, and extremities; she had a platelet count of 25,000/mm3. Nine days after discontinuation of both MTX and the NSAID, her platelet count increased to 189,000/mm3.
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Affiliation(s)
- D M Jih
- Department of Dermatology, University of Pennsylvania, and Philadelphia V.A. Hospital, 19104, USA
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