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Lend K, Koopman FA, Lampa J, Jansen G, Hetland ML, Uhlig T, Nordström D, Nurmohamed M, Gudbjornsson B, Rudin A, Østergaard M, Heiberg MS, Sokka-Isler T, Hørslev-Petersen K, Haavardsholm EA, Grondal G, Twisk JWR, van Vollenhoven R. Methotrexate Safety and Efficacy in Combination Therapies in Patients With Early Rheumatoid Arthritis: A Post Hoc Analysis of a Randomized Controlled Trial. Arthritis Rheumatol 2024; 76:363-376. [PMID: 37846618 DOI: 10.1002/art.42730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/29/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE We investigated methotrexate safety and the influence of dose on efficacy outcomes in combination with three different biologic treatments and with active conventional treatment (ACT) in early rheumatoid arthritis (RA). METHODS This post hoc analysis included 812 treatment-naïve patients with early RA who were randomized (1:1:1:1) in the NORD-STAR trial to receive methotrexate in combination with ACT, certolizumab-pegol, abatacept, or tocilizumab. Methotrexate safety, doses, and dose effects on Clinical Disease Activity Index (CDAI) remission were assessed after 24 weeks of treatment. RESULTS Compared with ACT, the prevalence of methotrexate-associated side effects was higher when methotrexate was combined with tocilizumab (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.20-1.84) but not with certolizumab-pegol (HR 0.99, 95% CI 0.79-1.23) or with abatacept (HR 0.93, 95% CI 0.75-1.16). With ACT as the reference, the methotrexate dose was significantly lower when used in combination with tocilizumab (β -4.65, 95% CI -5.83 to -3.46; P < 0.001) or abatacept (β -1.15, 95% CI -2.27 to -0.03; P = 0.04), and it was numerically lower in combination with certolizumab-pegol (β -1.07, 95% CI -2.21 to 0.07; P = 0.07). Methotrexate dose reductions were not associated with decreased CDAI remission rates within any of the treatment combinations. CONCLUSION Methotrexate was generally well tolerated in combination therapies, but adverse events were a limiting factor in receiving the target dose of 25 mg/wk, and these were more frequent in combination with tocilizumab versus ACT. On the other hand, methotrexate dose reductions were not associated with decreased CDAI remission rates within any of the four treatment combinations at 24 weeks.
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Affiliation(s)
- Kristina Lend
- Amsterdam University Medical Centers, Amsterdam, the Netherlands, and Karolinska Institute, Stockholm, Sweden
| | - Frieda A Koopman
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jon Lampa
- Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Gerrit Jansen
- Vrije Universiteit Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Merete L Hetland
- Copenhagen University Hospital Rigshospitalet, Glostrup, and University of Copenhagen, Copenhagen, Denmark
| | - Till Uhlig
- Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
| | - Dan Nordström
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Michael Nurmohamed
- Amsterdam University Medical Centers, Amsterdam, and Amsterdam Rheumatology and Immunology Center, Reade, the Netherlands
| | - Bjorn Gudbjornsson
- Landspitali University Hospital and University of Iceland, Reykjavik, Iceland
| | - Anna Rudin
- Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Mikkel Østergaard
- Copenhagen University Hospital Rigshospitalet, Glostrup, and University of Copenhagen, Copenhagen, Denmark
| | | | | | - Kim Hørslev-Petersen
- University Hospital of Southern Denmark, Sønderborg, and University of Southern Denmark, Odense, Denmark
| | | | - Gerdur Grondal
- Landspitali University Hospital and University of Iceland, Reykjavik, Iceland
| | - Jos W R Twisk
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ronald van Vollenhoven
- Amsterdam University Medical Centers, Amsterdam, the Netherlands, and Karolinska Institute, Stockholm, Sweden
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Leaviss J, Carroll C, Essat M, van der Windt D, Grainge MJ, Card T, Riley R, Abhishek A. Prognostic factors for liver, blood and kidney adverse events from glucocorticoid sparing immune-suppressing drugs in immune-mediated inflammatory diseases: a prognostic systematic review. RMD Open 2024; 10:e003588. [PMID: 38199851 PMCID: PMC10806492 DOI: 10.1136/rmdopen-2023-003588] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Immune-suppressing drugs can cause liver, kidney or blood toxicity. Prognostic factors for these adverse-events are poorly understood. PURPOSE To ascertain prognostic factors associated with liver, blood or kidney adverse-events in people receiving immune-suppressing drugs. DATA SOURCES MEDLINE, Web of Science, EMBASE and the Cochrane library (01 January 1995 to 05 January 2023), and supplementary sources. DATA EXTRACTION AND SYNTHESIS Data were extracted by one reviewer using a modified CHARMS-PF checklist and validated by another. Two independent reviewers assessed risk of bias using Quality in Prognostic factor Studies tool and assessed the quality of evidence using a Grading of Recommendations Assessment, Development and Evaluation-informed framework. RESULTS Fifty-six studies from 58 papers were included. High-quality evidence of the following associations was identified: elevated liver enzymes (6 studies) and folate non-supplementation (3 studies) are prognostic factors for hepatotoxicity in those treated with methotrexate; that mercaptopurine (vs azathioprine) (3 studies) was a prognostic factor for hepatotoxicity in those treated with thiopurines; that mercaptopurine (vs azathioprine) (3 studies) and poor-metaboliser status (4 studies) were prognostic factors for cytopenia in those treated with thiopurines; and that baseline elevated liver enzymes (3 studies) are a prognostic factor for hepatotoxicity in those treated with anti-tumour necrosis factors. Moderate and low quality evidence for several other demographic, lifestyle, comorbidities, baseline bloods/serologic or treatment-related prognostic factors were also identified. LIMITATIONS Studies published before 1995, those with less than 200 participants and not published in English were excluded. Heterogeneity between studies included different cut-offs for prognostic factors, use of different outcome definitions and different adjustment factors. CONCLUSIONS Prognostic factors for target-organ damage were identified which may be further investigated for their potential role in targeted (risk-stratified) monitoring. PROSPERO REGISTRATION NUMBER CRD42020208049.
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Affiliation(s)
- Joanna Leaviss
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Munira Essat
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Matthew J Grainge
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Richard Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
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3
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Arias-de la Rosa I, Ruiz-Ponce M, Cuesta-López L, Pérez-Sánchez C, Leiva-Cepas F, Gahete MD, Navarro P, Ortega R, Cordoba J, Pérez-Pampin E, González A, Lucendo AJ, Collantes-Estévez E, López-Pedrera C, Escudero-Contreras A, Barbarroja N. Clinical features and immune mechanisms directly linked to the altered liver function in patients with rheumatoid arthritis. Eur J Intern Med 2023; 118:49-58. [PMID: 37544847 DOI: 10.1016/j.ejim.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The aim of this study was to explore the impact of arthritis on liver function using different approaches in vivo and in vitro. METHODS A cross-sectional study was performed on 330 non-obese/non-T2DM subjects: 180 RA patients, 50 NAFLD non-RA patients, and 100 healthy donors (HDs). A longitudinal study was conducted on 50 RA patients treated with methotrexate for six months. Clinical and laboratory parameters and markers of liver disease were collected. Mechanistic studies were carried out in both the CIA mouse model and hepatocytes treated with anti-citrullinated protein antibodies (ACPAs). RESULTS RA patients have an increased risk of suffering from liver disease independent of obesity or T2DM. This risk was associated with factors such as insulin resistance, autoantibodies, inflammation, and component C3. Methotrexate treatment for six months was associated with liver abnormalities in those newly-diagnosed patients having CV risk factors. ACPAs induced a defective hepatocyte function, promoting IR and inflammation. The induction of arthritis in mice caused the infiltration of immune cells in the liver and increased inflammatory, apoptotic, and fibrotic processes. CONCLUSION RA patients may experience mild to moderate liver inflammation due to the infiltration of T, B cells, and macrophages, and the action of ACPAs. This is independent of obesity or diabetes and linked to systemic inflammation, and disease activity levels. The negative effects of methotrexate on liver function could be restricted to the concomitant presence of cardiovascular risk factors.
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Affiliation(s)
- I Arias-de la Rosa
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain.
| | - M Ruiz-Ponce
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - L Cuesta-López
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - C Pérez-Sánchez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - F Leiva-Cepas
- Deparment of Pathology, Reina Sofia University Hospital, Cordoba, Spain; Department of Morphological Sciences, Section of Histology, Faculty of Medicine and Nursing, Cordoba, Spain
| | - M D Gahete
- Department of Cell Biology, Physiology, and Immunology, Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, CIBERobn, Cordoba, Spain
| | - P Navarro
- Department of Gastroenterology. Hospital General de Tomelloso, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - R Ortega
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - J Cordoba
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL, USA
| | - E Pérez-Pampin
- Experimental and Observational Rheumatology and Rheumatology Unit, Instituto de Investigación Sanitaria - Hospital Clínico Universitario de Santiago (IDIS), Santiago de Compostela, Galicia, Spain
| | - A González
- Experimental and Observational Rheumatology and Rheumatology Unit, Instituto de Investigación Sanitaria - Hospital Clínico Universitario de Santiago (IDIS), Santiago de Compostela, Galicia, Spain
| | - A J Lucendo
- Department of Gastroenterology. Hospital General de Tomelloso, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - E Collantes-Estévez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - Ch López-Pedrera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - A Escudero-Contreras
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain
| | - N Barbarroja
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ /University of Cordoba/ Reina Sofia University Hospital, Córdoba, Spain.
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4
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Kuusalo L, Venäläinen MS, Kirjala H, Saranpää S, Elo LL, Pirilä L. Development of prediction model for alanine transaminase elevations during the first 6 months of conventional synthetic DMARD treatment. Sci Rep 2023; 13:12943. [PMID: 37558753 PMCID: PMC10412531 DOI: 10.1038/s41598-023-39694-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/29/2023] [Indexed: 08/11/2023] Open
Abstract
Frequent laboratory monitoring is recommended for early identification of toxicity when initiating conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). We aimed at developing a risk prediction model to individualize laboratory testing at csDMARD initiation. We identified inflammatory joint disease patients (N = 1196) initiating a csDMARD in Turku University Hospital 2013-2019. Baseline and follow-up safety monitoring results were drawn from electronic health records. For rheumatoid arthritis patients, diagnoses and csDMARD initiation/cessation dates were manually confirmed. Primary endpoint was alanine transaminase (ALT) elevation of more than twice the upper limit of normal (ULN) within 6 months after treatment initiation. Computational models for predicting incident ALT elevations were developed using Lasso Cox proportional hazards regression with stable iterative variable selection (SIVS) and were internally validated against a randomly selected test cohort (1/3 of the data) that was not used for training the models. Primary endpoint was reached in 82 patients (6.9%). Among baseline variables, Lasso model with SIVS predicted subsequent ALT elevations of > 2 × ULN using higher ALT, csDMARD other than methotrexate or sulfasalazine and psoriatic arthritis diagnosis as important predictors, with a concordance index of 0.71 in the test cohort. Respectively, at first follow-up, in addition to baseline ALT and psoriatic arthritis diagnosis, also ALT change from baseline was identified as an important predictor resulting in a test concordance index of 0.72. Our computational model predicts ALT elevations after the first follow-up test with good accuracy and can help in optimizing individual testing frequency.
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Affiliation(s)
- Laura Kuusalo
- Division of Medicine, Centre for Rheumatology and Clinical Immunology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-6, P.O. Box 52, 20521, Turku, Finland.
| | - Mikko S Venäläinen
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Tykistökatu 6, 20520, Turku, Finland
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Heidi Kirjala
- Division of Medicine, Centre for Rheumatology and Clinical Immunology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-6, P.O. Box 52, 20521, Turku, Finland
| | - Sofia Saranpää
- Division of Medicine, Centre for Rheumatology and Clinical Immunology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-6, P.O. Box 52, 20521, Turku, Finland
| | - Laura L Elo
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Tykistökatu 6, 20520, Turku, Finland
- Institute of Biomedicine, University of Turku, Turku, Finland
- InFLAMES Research Flagship Center, University of Turku, Turku, Finland
| | - Laura Pirilä
- Division of Medicine, Centre for Rheumatology and Clinical Immunology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-6, P.O. Box 52, 20521, Turku, Finland
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5
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AbdelKader G, Abdelaziz EZ, Hassan R, Greish SM, Abogresha NM, Sultan BO, Yousef EM, Morsi S. Protective Effects of Crocin Against Methotrexate-Induced Hepatotoxicity in Adult Male Albino Rats: Histological, Immunohistochemical, and Biochemical Study. Cureus 2023; 15:e34468. [PMID: 36874671 PMCID: PMC9981239 DOI: 10.7759/cureus.34468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Among the many known adverse effects of methotrexate (MTX), hepatotoxicity stands out as a major drawback that limits its therapeutic applicability. There is growing evidence that crocin has antioxidant, anti-hyperglycemic, cardioprotective, and anti-inflammatory effects. This study's aim is to evaluate the potential protective effect of crocin against MTX-induced liver damage in rats using biochemical, histological, and immunohistochemical analyses. METHODS Twenty-four adult male albino rats were split into four groups at random (six rats/group) as follows: normal control (saline, intraperitoneal (i.p.) injections), crocin-treated (100 mg/kg daily for 14 days, i.p.), MTX-treated (20 mg/kg single i.p. injection on day 15), and crocin/MTX-treated groups (crocin 100 mg/kg/day for 14 days, i.p. + MTX 20 mg/kg single i.p. injection on day 15). On day 16 of the experiment, blood and tissue specimens were used to assess the liver functions, oxidative stress markers, transforming growth factor beta 1 (TGF-β1), caspase-3, BCL-2-associated X protein (BAX), and B-cell lymphoma 2 (BCL-2) expression. RESULTS The results of the current research revealed the protective actions of crocin against MTX-induced hepatotoxicity. Our results showed that crocin possesses antioxidants (decrease malondialdehyde (MDA), increase glutathione (GSH) levels, and enhance catalase (CAT) and superoxide dismutase (SOD) enzymatic activity), anti-fibrotic (decrease TGF-β1), and anti-apoptotic (decrease BAX and caspase-3 expression while increase BCL-2) actions in liver. Moreover, crocin administration along with MTX restores the normal histological structure of hepatic tissues. CONCLUSION The data presented in the current study using an in vivo animal model support the notion that crocin should be further studied in humans to assess its potential hepatoprotective effects against MTX-induced liver damage.
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Affiliation(s)
- Ghada AbdelKader
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, EGY
| | - Eman Z Abdelaziz
- Department of Pharmacology, Faculty of Medicine, Suez Canal University, Ismailia, EGY
| | - Ranya Hassan
- Department of Clinical Pathology, Faculty of Medicine, Suez Canal University, Ismailia, EGY
| | - Sahar M Greish
- Department of Medical Physiology, Faculty of Medicine, Suez Canal University, Ismailia, EGY.,Department of Physiology, School of Medicine, Badr University in Cairo (BUC), Cairo, EGY
| | - Noha M Abogresha
- Department of Medical Physiology, Faculty of Medicine, Suez Canal University, Ismailia, EGY
| | - Basma O Sultan
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, EGY
| | - Einas M Yousef
- Department of Histology and Cell Biology, Faculty of Medicine, Menoufia University, Shibin El Kom, EGY
| | - Shereen Morsi
- Department of Medical Physiology, Faculty of Medicine, Suez Canal University, Ismailia, EGY
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6
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Cavalli M, Eriksson N, Sundbaum JK, Wallenberg M, Kohnke H, Baecklund E, Hallberg P, Wadelius M. Genome-wide association study of liver enzyme elevation in an extended cohort of rheumatoid arthritis patients starting low-dose methotrexate. Pharmacogenomics 2022; 23:813-820. [PMID: 36070248 DOI: 10.2217/pgs-2022-0074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/21/2022] Open
Abstract
Aim: A follow-up genome-wide association study (GWAS) in an extended cohort of rheumatoid arthritis (RA) patients starting low-dose methotrexate (MTX) treatment was performed to identify further genetic variants associated with alanine aminotransferase (ALT) elevation. Patients & methods: A GWAS was performed on 346 RA patients. Two outcomes within the first 6 months of MTX treatment were assessed: ALT >1.5-times the upper level of normal (ULN) and maximum level of ALT. Results: SPATA9 (rs72783407) was significantly associated with maximum level of ALT (p = 2.58 × 10-8) and PLCG2 (rs60427389) was tentatively associated with ALT >1.5 × ULN. Conclusion: Associations with SNPs in genes related to male fertility (SPATA9) and inflammatory processes (PLCG2) were identified.
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Affiliation(s)
- Marco Cavalli
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden.,Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, SE-751 22, Uppsala, Sweden
| | - Niclas Eriksson
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden.,Uppsala Clinical Research Center, SE-751 85, Uppsala, Sweden
| | - Johanna Karlsson Sundbaum
- Department of Medical Sciences, Rheumatology, Uppsala University, SE-751 85, Uppsala, Sweden.,Department of Health Sciences, Luleå University of Technology, SE-971 87, Luleå, Sweden
| | - Matilda Wallenberg
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden.,Svensk Dos AB, Box 2, SE-751 03, Uppsala, Sweden
| | - Hugo Kohnke
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Rheumatology, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
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Matsuo H, Kamada M, Imamura A, Shimizu M, Inagaki M, Tsuji Y, Hashimoto M, Tanaka M, Ito H, Fujii Y. Machine learning-based prediction of relapse in rheumatoid arthritis patients using data on ultrasound examination and blood test. Sci Rep 2022; 12:7224. [PMID: 35508670 DOI: 10.1038/s41598-022-11361-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/22/2022] [Indexed: 11/08/2022] Open
Abstract
Recent effective therapies enable most rheumatoid arthritis (RA) patients to achieve remission; however, some patients experience relapse. We aimed to predict relapse in RA patients through machine learning (ML) using data on ultrasound (US) examination and blood test. Overall, 210 patients with RA in remission at baseline were dichotomized into remission (n = 150) and relapse (n = 60) based on the disease activity at 2-year follow-up. Three ML classifiers [Logistic Regression, Random Forest, and extreme gradient boosting (XGBoost)] and data on 73 features (14 US examination data, 54 blood test data, and five data on patient information) at baseline were used for predicting relapse. The best performance was obtained using the XGBoost classifier (area under the receiver operator characteristic curve (AUC) = 0.747), compared with Random Forest and Logistic Regression (AUC = 0.719 and 0.701, respectively). In the XGBoost classifier prediction, ten important features, including wrist/metatarsophalangeal superb microvascular imaging scores, were selected using the recursive feature elimination method. The performance was superior to that predicted by researcher-selected features, which are conventional prognostic markers. These results suggest that ML can provide an accurate prediction of relapse in RA patients, and the use of predictive algorithms may facilitate personalized treatment options.
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8
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Wang Y, Li Y, Liu Y, Zhang Y, Ke Z, Zhang Y, Liu Y. Patients With IBD Receiving Methotrexate Are at Higher Risk of Liver Injury Compared With Patients With Non-IBD Diseases: A Meta-Analysis and Systematic Review. Front Med (Lausanne) 2021; 8:774824. [PMID: 34881269 PMCID: PMC8645797 DOI: 10.3389/fmed.2021.774824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Methotrexate is well-known in treating inflammatory bowel disease (IBD), rheumatoid arthritis (RA), psoriasis (Ps), and psoriatic arthritis (PsA). Several reports have indicated a higher incidence of methotrexate (MTX)-related liver adverse events in patients with IBD. We aim to investigate the risk of liver injury in patients with IBD and those with non-IBD diseases treated with MTX. Methods: We searched PubMed, Embase, and the Cochrane Library for articles that reported liver adverse events in patients with IBD, RA, and Ps/PsA, receiving MTX therapy. Additional articles were obtained by screening the references of recent meta-analysis and reviews. Raw data from included articles were pooled to calculate the cumulative incidence of total liver injury (TLI), MTX discontinuation (MTX-D), and liver fibrosis (LF). RR (relative risk) was calculated to compare the difference between patients with IBD and those with non-IBD diseases. Results: A total of 326 articles with 128,876 patients were included. The patients with IBD had higher incidence of TLI [11.2 vs. 9.2%; relative risk (RR) = 1.22; P = 0.224] and MTX-D (2.6 vs. 1.8%; RR, 1.48; P = 0.089) than patients with non-IBD diseases. Due to the publication bias, trim-and-fill was performed. Afterwards, the patients with IBD showed significantly higher risk of TLI (11.2 vs. 3%; RR = 3.76; p < 0.001), MTX-D (3.3 vs. 0.7%; RR = 5; p < 0.001) and LF (3.1 vs. 0.1%; RR = 38.62; P = 0.001) compared with patients with non-IBD diseases. Conclusion: IBD is associated with a higher risk of MTX-related liver injury. The mechanism of MTX-induced hepatotoxicity might be different in IBD and non-IBD diseases, and needs to be verified in future research.
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Affiliation(s)
- Yang Wang
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
| | - Yimin Li
- Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Yun Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
| | - Yifan Zhang
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
| | - Ziliang Ke
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
| | - Yu Zhang
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
| | - Yulan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing, China.,Clinical Center of Immune-Mediated Digestive Diseases, Peking University People's Hospital, Beijing, China
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Ibrahim SSA, Kandil LS, Ragab GM, El-Sayyad SM. Micro RNAs 26b, 20a inversely correlate with GSK-3 β/NF-κB/NLRP-3 pathway to highlight the additive promising effects of atorvastatin and quercetin in experimental induced arthritis. Int Immunopharmacol 2021; 99:108042. [PMID: 34426107 DOI: 10.1016/j.intimp.2021.108042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 12/23/2022]
Abstract
Rheumatoid arthritis (RA) is an inflammatory disease with challenging therapeutic potential due to the implication of cross-talking intracellular pathways in the pathogenesis of the disease. This study aimed to evaluate the effects of the combination therapy of atorvastatin and quercetin on glycogen synthase kinase-3 beta/ nuclear factor kappa-B/ nucleotide-binding oligomerization domain-like receptor family pyrin domain containing-3 or inflammasome (GSK-3β/NF-KB/NLRP-3) pathway as well as on microRNAs 26b and 20a (miR-26b, miR-20a) and to investigate the possible beneficial outcomes of the combination to offer a better treatment option than methotrexate (MTX) in adjuvant-induced arthritis (AIA). Assessment of arthritis progression, serum inflammatory, and oxidative parameters were done. The tibiotarsal tissue expression of the inflammatory parameters was evaluated. Western blot analysis was done to assess the expression level of the important members in the GSK-3β/NF-κB/NLRP-3 pathway. Furthermore, the expression level of both microRNAs and serum level of transaminases were determined. All treatments, especially the combination regimen, abated arthritis progression, the elevated serum level of inflammatory and oxidative stress parameters in arthritic rats. Moreover, They down-regulated the gene expression of the important members of the aforementioned signaling pathway, amended the tissue levels of inflammatory parameters and elevated the expression level of miR-26b and miR-20a. Finally, we concluded that the combination therapy modulated miR-26b and miR-20a as well as GSK-3β/NF-κB/NLRP-3 pathway, provided additive anti-inflammatory and anti-oxidant effects and offered an additional hepatoprotective effect as compared to untreated arthritic rats and MTX-treated groups, suggesting its promising role to be used as replacement therapy to MTX in RA.
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Affiliation(s)
| | - Lamia Said Kandil
- Department of Pharmacology & Therapeutics, Pharos University in Alexandria, Alexandria, Egypt; Department of Biochemistry, School of Biological Sciences, University of East Anglia, England
| | - Ghada M Ragab
- Department of Pharmacology and Toxicology, Misr University for Science and Technology, 6(th) of October City, Egypt
| | - Shorouk M El-Sayyad
- Department of Pharmacology & Toxicology, October 6 University, 12585, Giza, Egypt
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10
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Sundbaum JK, Baecklund E, Eriksson N, Kohnke H, Wallenberg M, Cavalli M, Wadelius C, Wadelius M, Hallberg P. Genome-wide association study of liver enzyme elevation in rheumatoid arthritis patients starting methotrexate. Pharmacogenomics 2021; 22:973-982. [PMID: 34521259 DOI: 10.2217/pgs-2021-0064] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 12/19/2022] Open
Abstract
Aim: To identify novel genetic variants predisposing to elevation of Alanine aminotransferase (ALT) in rheumatoid arthritis (RA) patients after initiation of methotrexate (MTX) treatment. Patients & methods: We performed genome-wide association studies in 198 RA patients starting MTX. Outcomes were maximum level of ALT and ALT >1.5-times the upper level of normal within the first 6 months of treatment. Results: RAVER2 (rs72675408) was significantly associated with maximum level of ALT (p = 4.36 × 10-8). This variant is in linkage disequilibrium with rs72675451, which is associated with differential expression of JAK1 and RAVER2. Conclusion: We found an association between ALT elevation and genetic variants that may regulate the expression of JAK1 and RAVER2. JAK1 encodes a janus kinase involved in the pathogenesis of RA.
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Affiliation(s)
- Johanna Karlsson Sundbaum
- Department of Medical Sciences, Rheumatology, Uppsala University, SE-751 85, Uppsala, Sweden.,Department of Health Sciences, Luleå University of Technology, SE-971 87, Luleå, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Rheumatology, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Niclas Eriksson
- Uppsala Clinical Research center, SE-751 85, Uppsala, Sweden.,Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Hugo Kohnke
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Matilda Wallenberg
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden.,Svensk Dos AB, Box 2, SE-751 03, Uppsala, Sweden
| | - Marco Cavalli
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, SE-751 22, Uppsala, Sweden
| | - Claes Wadelius
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, SE-751 22, Uppsala, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, SE-751 85, Uppsala, Sweden
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11
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Escudero-Contreras A, López-Medina C, Collantes-Estévez E, Ortega-Castro R, Calvo-Gutiérrez J, Mena-Vázquez N, Panero-Lamothe B, Manzanares-Martín B, Cáliz-Cáliz R, Jiménez-Morales A, Ruiz-Jiménez M, Font-Ugalde P. Genetic Polymorphisms of GGH and ABCC2 Are Associated with Methotrexate Intolerance in Patients with Rheumatoid Arthritis. J Clin Med 2021; 10:jcm10184070. [PMID: 34575187 PMCID: PMC8472669 DOI: 10.3390/jcm10184070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE to identify new single-nucleotide polymorphisms (SNPs) in genes encoding proteins involved in methotrexate (MTX) metabolism and to evaluate the associations of these SNPs with MTX toxicity or intolerance in a southern Spanish cohort of patients with rheumatoid arthritis (RA). METHODS An observational, retrospective, and multicenter study was conducted at three participating hospitals in southern Spain. The main variable was intolerance to MTX (i.e., bDMARD monotherapy), defined as an interruption of treatment due to adverse events or toxicity. Patients being treated with MTX and bDMARDs (combined treatment) at the time of the study visit were considered "tolerant" of MTX. Ten polymorphisms were selected for sequencing in our patients according to a literature review. Each polymorphism was classified according to three possible genotypes (e.g., two homozygous (AA or GG) and one heterozygous (AG)), and the association of these combinations with MTX intolerance was evaluated. RESULTS A total of 227 patients were included in the final analysis (107 intolerant of MTX and 120 tolerant). A significant association was observed between MTX intolerance and the GGH-T401C AA/AG genotype (OR 2.13, 95% CI 1.06-4.29) in comparison with the GG genotype. On the other hand, an inverse association was observed between the ABCC2-C24T TT/TC genotype and intolerance to MTX (OR 0.59, 95% CI 0.35-1.00) in comparison with the CC genotype. CONCLUSION This study provides new data on the association between genetic polymorphisms and MTX intolerance, which may contribute to the development of new biomarkers and personalized medicine in patients with RA.
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Affiliation(s)
- Alejandro Escudero-Contreras
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
| | - Clementina López-Medina
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
- Correspondence:
| | - Eduardo Collantes-Estévez
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
| | - Rafaela Ortega-Castro
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
| | - Jerusalem Calvo-Gutiérrez
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
| | - Natalia Mena-Vázquez
- Institute of Biomedical Research from Malaga (IBIMA), 29010 Malaga, Spain; (N.M.-V.); (B.P.-L.)
- Rheumatology Department, Regional University Hospital from Malaga, 29010 Malaga, Spain
| | - Blanca Panero-Lamothe
- Institute of Biomedical Research from Malaga (IBIMA), 29010 Malaga, Spain; (N.M.-V.); (B.P.-L.)
- Rheumatology Department, Regional University Hospital from Malaga, 29010 Malaga, Spain
| | - Bárbara Manzanares-Martín
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Immunology and Allergology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain
| | - Rafael Cáliz-Cáliz
- Rheumatology Department, Virgen de las Nieves University Hospital, 18014 Granada, Spain;
| | | | | | - Pilar Font-Ugalde
- Rheumatology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (A.E.-C.); (E.C.-E.); (R.O.-C.); (J.C.-G.); (P.F.-U.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Medical and Surgical Sciences Department, University of Cordoba, 14004 Cordoba, Spain
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12
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Ezhilarasan D. Hepatotoxic potentials of methotrexate: Understanding the possible toxicological molecular mechanisms. Toxicology 2021; 458:152840. [PMID: 34175381 DOI: 10.1016/j.tox.2021.152840] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 12/12/2022]
Abstract
Methotrexate (MTX) is one of the most effective and widely used drugs in the management of autoimmune and dermatological diseases. Rheumatoid arthritis and psoriasis patients who are under long term MTX-therapy are at high risk of developing a liver injury. Accumulation of intracellular MTX-polyglutamate (MTX-PG), a metabolite of MTX triggers oxidative stress, inflammation, steatosis, fibrosis, and apoptosis in hepatocytes. MTX-PG causes oxidative stress in the liver by inducing lipid peroxidation thereby releasing reactive oxygen species and suppressing antioxidant response elements. MTX-PG induces several pro-inflammatory signaling pathways and cytokines such as tumor necrosis factor-α, nuclear factor kappa B and interleukin 6 (IL-6), IL- β1, IL-12. MTX-PG depletes hepatic folate level and decreases RNA and DNA synthesis leading to hepatocyte death. MTX-PG inhibits 5-aminoimidazole-4-carboxamide ribonucleotide transformylase enzyme and thereby causes accumulation of intracellular adenosine, which causes activation of hepatic stellate cells, extracellular matrix accumulation and hepatic fibrosis. MTX-PG induces hepatocytes apoptosis by activation of caspase 3 via the intrinsic pathway. Clinically, aggravation of underlying fatty liver to non-alcoholic steatohepatitis with fibrosis seems to be an important mechanism of liver injury in MTX-treated RA patients. Therefore, there is a need for monitoring liver injury in RA, psoriatic and cancer patients with NAFLD and fibrosis risk factors during MTX treatment. This review summarizes the possible molecular mechanism of MTX-induced hepatotoxicity. It may pave the way for early detection of liver injury and develop novel strategies for treating MTX mediated hepatotoxicity.
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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14
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Choi SR, Park JW, Lee EB, Park JK. Initial methotrexate dosage is not associated with an increased risk of liver toxicity in patients with rheumatoid arthritis. Clin Rheumatol 2021. [PMID: 34115231 DOI: 10.1007/s10067-021-05811-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/25/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of this study is to determine whether an initial methotrexate (MTX) dosage is associated with an increased risk of liver toxicity in patients with rheumatoid arthritis (RA). METHODS This retrospective study included 730 RA patients who started MTX treatment between 2004 and 2019 at the rheumatology clinic at Seoul National University Hospital. The patients were divided into three groups according to the initial dosage of MTX they received: low (MTX ≤ 7.5 mg/week), intermediate (MTX 10-12.5 mg/week), and high (MTX ≥ 15 mg/week) dosage groups. Hepatotoxicity, defined as elevations in aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) levels more than twofold above the upper limit of normal (2 × ULN), was examined during 90 days of MTX treatment. Predictors of hepatotoxicity were identified using logistic regression analyses. RESULTS Of the 730 patients, 10 (1.4%) patients developed hepatotoxicity. The rate of hepatotoxicity was not different between the three MTX dosage groups. Univariate logistic regression analyses showed that the risk of hepatotoxicity was not higher in the intermediate MTX dosage group (odds ratio (OR): 0.89, 95% confidential interval (CI): 0.20-4.00, p = 0.877) or in the high MTX dosage group (OR: 1.23, 95% CI: 0.24-6.14, p = 0.804) than in the low MTX dosage group. Multivariate logistic regression analyses showed that elevated baseline AST and/or ALT levels above ULN and concomitant leflunomide use were associated with MTX hepatotoxicity. CONCLUSION The initial MTX dosage is not associated with increased hepatotoxicity in RA patients. KEY POINTS • An initial methotrexate (MTX) dosage is not associated with liver toxicity in patients with rheumatoid arthritis (RA). • RA patients with a baseline liver function test (LFT) abnormality or receiving concomitant leflunomide treatment should be monitored closely for LFT abnormalities during the early phase of MTX treatment.
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15
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Choi Y, Lee CH, Kim IH, Park EH, Park S, Yoo WH. Methotrexate use does not increase the prevalence of hepatic steatosis: a real-world retrospective nested case-control study. Clin Rheumatol 2020; 40:2037-2045. [PMID: 33078254 DOI: 10.1007/s10067-020-05456-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We aimed to determine whether methotrexate (MTX) treatment in patients with rheumatoid arthritis (RA) leads to the development of non-alcoholic fatty liver (NAFL). METHOD Data were derived from records of all patients with RA who underwent abdominal ultrasonography at the Jeonbuk National University Hospital. Patients with ultrasound-proven NAFL were identified, and those without NAFL were matched by age and sex using the propensity score matching method at 1:3 ratio. We also analyzed the Health Insurance Review and Assessment Service-National Patient Samples, a nationwide cohort database, to determine the association between MTX use and NAFL in a large number of patients (n = 24,653). RESULTS In the hospital cohort, 92 patients with NAFL did not show significant differences in the cumulative MTX dose when compared with the no-NAFL group (n = 276) (1908.5 ± 1757.5 vs. 1948.6 ± 2118.8 mg, p = 0.911). The prevalence of NAFL was not significantly different across strata of cumulative MTX dose. Multiple logistic analyses identified hypertriglyceridemia (OR, 4.88 [95% CI, 1.13-20.93]) and higher body mass index (OR, 1.22 [95% CI, 1.05-1.41]) as being associated with an increased risk of NAFL. In the nationwide cohort, the MTX exposure rate between the NAFL and no-NAFL groups was not significantly different. CONCLUSIONS Collectively, no significant association between NAFL development and administration of MTX was detected in this study. Our results suggest that it is more efficient to adjust for individualized risk factors for NAFL prevention rather than discontinuation of MTX in patients with RA. Key Points • NAFLD has been highlighted with increasing prevalence worldwide and possible progression to end-stage liver disease. • Cumulative dose or exposure history of MTX does not show a significant association with NAFLD prevalence. • Modifying well-established risk factors is more efficient in NAFLD prevention rather than discontinuation of MTX.
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Affiliation(s)
- Yunjung Choi
- Division of Rheumatology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Chang Hun Lee
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.,Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, South Korea
| | - In Hee Kim
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.,Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, South Korea
| | - Eun Hae Park
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.,Department of Radiology, Jeonbuk National University Hospital, Jeonju, South Korea
| | - SoJeong Park
- Data Science Team, Hanmi Pharm. Co., Ltd, Seoul, South Korea
| | - Wan-Hee Yoo
- Division of Rheumatology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, South Korea. .,Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
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16
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Sundbaum JK, Baecklund E, Eriksson N, Hallberg P, Kohnke H, Wadelius M. MTHFR, TYMS and SLCO1B1 polymorphisms and adverse liver effects of methotrexate in rheumatoid arthritis. Pharmacogenomics 2020; 21:337-346. [PMID: 32024416 DOI: 10.2217/pgs-2019-0186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] Open
Abstract
Aims: To investigate whether variants of MTHFR, TYMS and SLCO1B1 are associated with ALT elevation in rheumatoid arthritis patients starting methotrexate (MTX). Patients & methods: Clinical and laboratory data were collected from the start of MTX treatment. Genotyping of MTHFR, TYMS and SLCO1B1 was performed. Univariate and multiple logistic regression were used for statistical analysis. Results: 34 out of 369 patients experienced ALT >1.5 × ULN less than 6 months from start. MTHFR A1298C (rs1801131) was nominally associated with an ALT >1.5 × ULN within 6 months after the start of MTX (OR = 1.7 [95% CI: 1.04-2.9]; p = 0.03), but did not pass correction for multiple testing. A multiple model containing MTHFR 1298C and clinical factors predicted the outcome (C-statistic 0.735). TYMS and SLCO1B1 were not associated with the outcome. Conclusions: A model containing MTHFR 1298C and clinical factors might predict risk of early ALT elevation.
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Affiliation(s)
- Johanna Karlsson Sundbaum
- Department of Medical Sciences, Rheumatology, Uppsala University, Sweden.,Department of Health Sciences, Luleå University of Technology, Luleå
| | - Eva Baecklund
- Department of Medical Sciences, Rheumatology, Uppsala University, Sweden
| | - Niclas Eriksson
- Department of Medical Sciences, Clinical Pharmacology & Science for Life Laboratory, Uppsala University, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology & Science for Life Laboratory, Uppsala University, Sweden
| | - Hugo Kohnke
- Department of Medical Sciences, Clinical Pharmacology & Science for Life Laboratory, Uppsala University, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology & Science for Life Laboratory, Uppsala University, Sweden
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17
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Karlsson Sundbaum J, Eriksson N, Hallberg P, Lehto N, Wadelius M, Baecklund E. Methotrexate treatment in rheumatoid arthritis and elevated liver enzymes: A long-term follow-up of predictors, surveillance, and outcome in clinical practice. Int J Rheum Dis 2019; 22:1226-1232. [PMID: 31012257 PMCID: PMC6767545 DOI: 10.1111/1756-185x.13576] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/01/2019] [Accepted: 03/18/2019] [Indexed: 01/05/2023]
Abstract
Aim To assess predictors of alanine aminotransferase (ALT) elevation in methotrexate (MTX) treated rheumatoid arthritis (RA) patients, and to describe the monitoring of liver enzymes, including handling and outcome of elevated ALT. Methods All RA patients starting MTX in January, 2005 to April, 2013 at a rheumatology clinic, (Uppsala University Hospital, Sweden) were identified from electronic medical records. Clinical and laboratory data were obtained from medical records, supplemented by telephone interviews. Predictors for ALT >1.5× over the upper limit of normal (ULN) were identified by multiple regression analysis. Results The study comprised 213 RA patients starting MTX. During a mean follow‐up of 4.3 years, 6288 ALT tests were performed; 7% of tests with ALT were >ULN. ALT >1.5× ULN was observed in 44 (21%) patients and the strongest predictor was a pre‐treatment elevation of ALT (adjusted odds ratio = 6.8, 95% CI 2.2‐20.5). Recurrent elevations occurred in 70% of patients who continued treatment, and the proportion was similar in those with and without interventions, for example MTX dose reduction (67% vs 73%, P = 0.43). Seven patients (3%) permanently stopped MTX due to ALT elevation, and two were eventually diagnosed with non‐alcoholic fatty liver disease. No patient developed hepatic failure. Conclusion Only a small number of ALT tests performed during MTX therapy in RA capture an elevation. A pre‐treatment elevation of ALT was the strongest predictor for early and recurrent ALT elevations during therapy. This study supports a more individualized approach to monitoring and handling of ALT elevations during MTX therapy in RA than recommended in current guidelines.
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Affiliation(s)
- Johanna Karlsson Sundbaum
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden.,Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Niclas Eriksson
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Niklas Lehto
- Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
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