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Siegfried EC, Arkin LM, Chiu YE, Hebert AA, Callen JP, Castelo-Soccio L, Co DO, Cordoro KM, Curran ML, Dalrymple AM, Flohr C, Gordon KB, Hanna D, Irvine AD, Kim S, Kirkorian AY, Lara-Corrales I, Lindstrom J, Paller AS, Reyes M, Begolka WS, Tom WL, Van Voorhees AS, Vleugels RA, Lee LW, Davies OMT, Brandling-Bennett HA. Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines. Pediatr Dermatol 2023; 40:789-808. [PMID: 37316462 DOI: 10.1111/pde.15327] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/26/2023] [Indexed: 06/16/2023]
Abstract
Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication.
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Affiliation(s)
- Elaine C Siegfried
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lisa M Arkin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yvonne E Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adelaide A Hebert
- UTHealth McGovern Medical School at Houston, Houston, Texas, United States
| | - Jeffrey P Callen
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Leslie Castelo-Soccio
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic O Co
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Megan L Curran
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Austin M Dalrymple
- SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Carsten Flohr
- Department of Paediatric Dermatology, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ken B Gordon
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | - Susan Kim
- University of California, San Francisco, California, USA
| | - A Yasmine Kirkorian
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Children's National Hospital, Washington, DC, USA
| | | | - Jill Lindstrom
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melissa Reyes
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | | | - Wynnis L Tom
- University of California, San Diego School of Medicine, San Diego, California, USA
- Rady Children's Hospital-San Diego, San Diego, California, USA
| | | | - Ruth Ann Vleugels
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Wine Lee
- Medical University of South Carolina, Charleston, South Carolina, USA
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Shea B, Swinden MV, Ghogomu ET, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells GA, Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. J Rheumatol 2014; 41:1049-60. [PMID: 24737913 DOI: 10.3899/jrheum.130738] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To perform a systematic review of the benefits and harms of folic acid and folinic acid in reducing the mucosal, gastrointestinal, hepatic, and hematologic side effects of methotrexate (MTX); and to assess whether folic or folinic acid supplementation has any effect on MTX benefit. METHODS We searched the Cochrane Library, MEDLINE, EMBASE, and US National Institutes of Health clinical trials registry from inception to March 2012. We selected all double-blind, randomized, placebo-controlled clinical trials in which adult patients with rheumatoid arthritis (RA) were treated with MTX (dose ≤ 25 mg/week) concurrently with folate supplementation. We included only trials using low-dose folic or folinic acid (a starting dose of ≤ 7 mg weekly) because the high dose is no longer recommended or used. Data were extracted from the trials, and the trials were independently assessed for risk of bias using a predetermined set of criteria. RESULTS Six trials with 624 patients were eligible for inclusion. Most studies had low or unclear risk of bias for key domains. The quality of the evidence was rated as "moderate" for each outcome as assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group, with the exception of hematologic side effects, which were rated as "low." There was no significant heterogeneity between trials, including where folic acid and folinic acid studies were pooled. For patients supplemented with any form of exogenous folate (either folic or folinic acid) while receiving MTX therapy for RA, a 26% relative (9% absolute) risk reduction was seen for the incidence of gastrointestinal side effects such as nausea, vomiting, or abdominal pain (RR 0.74, 95% CI 0.59 to 0.92; p = 0.008). Folic and folinic acid also appear to be protective against abnormal serum transaminase elevation caused by MTX, with a 76.9% relative (16% absolute) risk reduction (RR 0.23, 95% CI 0.15 to 0.34; p < 0.00001), as well as reducing patient withdrawal from MTX for any reason [60.8% relative (15.2% absolute) risk reduction, RR 0.39, 95% CI 0.28 to 0.53; p < 0.00001]. CONCLUSION The results support a protective effect of supplementation with either folic or folinic acid for patients with RA during treatment with MTX. There was a clinically important significant reduction shown in the incidence of GI side effects and hepatic dysfunction (as measured by elevated serum transaminase levels), as well as a clinically important significant reduction in discontinuation of MTX treatment for any reason.
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Affiliation(s)
- Beverley Shea
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program.
| | - Michael V Swinden
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Elizabeth Tanjong Ghogomu
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Zulma Ortiz
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Wanruchada Katchamart
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Tamara Rader
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Claire Bombardier
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - George A Wells
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
| | - Peter Tugwell
- From the Bruyère Research Institute (BRI); Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada; Epidemiological Research Center, National Academy of Medicine, Buenos Aires, Argentina; Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Cochrane Musculoskeletal Group, Ottawa; Institute for Work and Health, Toronto; Department of Epidemiology and Community Medicine, and the Department of Medicine, Faculty of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Clinical Epidemiology Program; Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.B. Shea, PhD, MSc, RN, BRI, Department of Epidemiology and Community Medicine, University of Ottawa; M.V. Swinden, MBBS; E. Tanjong Ghogomu, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa; Z. Ortiz, MD, MSc, Epidemiological Research Center, National Academy of Medicine; W. Katchamart, MD, FRCP, MSc, Rheumatology Division, Department of Medicine, Siriraj Hospital, Mahidol University; T. Rader, MLIS, Cochrane Musculoskeletal Group; C. Bombardier, MD, FRCPC, Institute for Work and Health; G.A. Wells, PhD, MSc, Department of Epidemiology and Community Medicine, University of Ottawa; P. Tugwell, MD, FRCPC, MSc, Department of Medicine, Faculty of Medicine, Institute of Population Health and Department of Epidemiology and Community Medicine, University of Ottawa; and Ottawa Hospital Research Institute, Clinical Epidemiology Program
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