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Current Rheumatology Reviews

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ISSN (Print): 1573-3971
ISSN (Online): 1875-6360

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Research Article

Methotrexate Hepatotoxicity in Rheumatoid Arthritis: An Analysis of the Physicians’ Policy

Author(s): Bita Anvari*

Volume 16, Issue 1, 2020

Page: [67 - 73] Pages: 7

DOI: 10.2174/1573397115666190618124407

Price: $65

Abstract

Background: Methotrexate hepatotoxicity could be a reason for the discontinuation or dose reduction in patients with Rheumatoid Arthritis (RA); however, the consequence of different policies in this situation is unclear and the physicians need to know what would happen after their decision.

Objective: To demonstrate the consequence of multiple approaches towards transaminitis management in patients with RA receiving Methotrexate (MTX).

Methods: Data were obtained from the previous work (2006) on 295 patients with RA undergoing MTX treatment. Those who developed transaminitis at least one time were selected for this study. Then, the physicians’ decisions regarding discontinuing, decreasing, or prescribing a fixed dose of MTX along with the effect of each decision on the next liver enzyme were evaluated.

Results: Strategies of decreasing dose or discontinuing MTX were adopted in 31.4% of patients and prescribing fixed dose was done in 53.9% of patients, leading to 93% and 65% next enzyme normalization, respectively. Thirty-four patients had definite MTX induced transaminitis and 55.9% of the physicians decided to decrease MTX dose for them, causing normalization of the next enzyme in 83% of these patients. In contrast, continuing MTX, even with the same dose, in definite MTX induced transaminitis cases led to consecutive enzyme elevations in 88.9% of these patients (p=0.001).

Conclusion: Normalization of liver enzymes was observed after decreasing dose or discontinuing MTX, suggesting this policy as the best practice for the management of MTX induced transaminitis. However, the trend to improvement, despite the type of physicians’ decision, was observed. This trend was not found in definite MTX induced transaminitis, revealing the prominence of the physician’s policy in this situation.

Keywords: Methotrexate, hepatotoxicity, physicians’ policy, transaminitis, rheumatoid arthritis, DMARD.

« Previous Next »
[1]
Yazici Y, Erkan D, Harrison MJ, Nikolov NP, Paget SA. Methotrexate use in rheumatoid arthritis is associated with few clinically significant liver function test abnormalities. Clin Exp Rheumatol 2005; 23(4): 517-20.
[PMID: 16095122]
[2]
Malik AR, Pavesio C. The use of low dose methotrexate in children with chronic anterior and intermediate uveitis. Br J Ophthalmol 2005; 89(7): 806-8.
[http://dx.doi.org/10.1136/bjo.2004.054239] [PMID: 15965154]
[3]
Alarcón GS, Tracy IC, Blackburn WD Jr. Methotrexate in rheumatoid arthritis. Toxic effects as the major factor in limiting long-term treatment. Arthritis Rheum 1989; 32(6): 671-6.
[http://dx.doi.org/10.1002/anr.1780320603] [PMID: 2735960]
[4]
Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis Rheum 1996; 39(5): 723-31.
[http://dx.doi.org/10.1002/art.1780390503] [PMID: 8639168]
[5]
Cash JM, Klippel JH. Second-line drug therapy for rheumatoid arthritis. N Engl J Med 1994; 330(19): 1368-75.
[http://dx.doi.org/10.1056/NEJM199405123301908] [PMID: 8152450]
[6]
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002; 46(2): 328-46.
[http://dx.doi.org/10.1002/art.10148] [PMID: 11840435]
[7]
Chughlay M, Blockman M, Cohen K. A clinical approach to drug-induced liver injury: review article. Curr Allergy Clin Immunol 2015; 28(4): 252-6.
[8]
Tajiri K, Shimizu Y. Practical guidelines for diagnosis and early management of drug-induced liver injury. World J Gastroenterol 2008; 14(44): 6774-85.
[http://dx.doi.org/10.3748/wjg.14.6774] [PMID: 19058303]
[9]
Curtis JR, Beukelman T, Onofrei A, et al. Elevated liver enzyme tests among patients with rheumatoid arthritis or psoriatic arthritis treated with methotrexate and/or leflunomide. Ann Rheum Dis 2010; 69(1): 43-7.
[http://dx.doi.org/10.1136/ard.2008.101378] [PMID: 19147616]
[10]
Conway R, Carey JJ. Risk of liver disease in methotrexate treated patients. World J Hepatol 2017; 9(26): 1092-100.
[http://dx.doi.org/10.4254/wjh.v9.i26.1092] [PMID: 28989565]
[11]
American Gastroenterological Association medical position statement: Evaluation of liver chemistry tests, This document presents the official recommendations of the American Gastroenterological Association (AGA) on the Evaluation of Liver Chemistry Tests. It was approved by the Clinical Practice Committee on March 3, 2002 and by the AGA Governing Board on May 19, 2002. Gastroenterology 2002; 123(4): 1364-6.
[12]
Oh RC, Hustead TR. Causes and evaluation of mildly elevated liver transaminase levels. Am Fam Physician 2011; 84(9): 1003-8.
[PMID: 22046940]
[13]
Aragon G, Younossi ZM. When and how to evaluate mildly elevated liver enzymes in apparently healthy patients. Cleve Clin J Med 2010; 77(3): 195-204.
[http://dx.doi.org/10.3949/ccjm.77a.09064] [PMID: 20200170]
[14]
Chalasani NP, Hayashi PH, Bonkovsky HL, Navarro VJ, Lee WM, Fontana RJ. Practice parameters committee of the american college of gastroenterology. ACG clinical guideline: the diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol 2014; 109(7): 950-66.
[http://dx.doi.org/10.1038/ajg.2014.131] [PMID: 24935270]
[15]
Corsini A, Bortolini M. Drug-induced liver injury: the role of drug metabolism and transport. J Clin Pharmacol 2013; 53(5): 463-74.
[http://dx.doi.org/10.1002/jcph.23] [PMID: 23436293]
[16]
Nguyen-Lefebvre AT, Horuzsko A. Kupffer Cell Metabolism and FunctionJournal of enzymology and metabolism 2015; 1(1): 101
[17]
O’Connell TM, Watkins PB. The application of metabonomics to predict drug-induced liver injury. Clin Pharmacol Ther 2010; 88(3): 394-9.
[http://dx.doi.org/10.1038/clpt.2010.151] [PMID: 20668441]
[18]
Sharma S, Anand G, Arora T. General concepts of drug induced liver injury. Int J Res Pharm Sci 2011; 1(2): 18-30.
[19]
Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology 2002; 123(4): 1367-84.
[http://dx.doi.org/10.1053/gast.2002.36061] [PMID: 12360498]
[20]
Khodadoostan M, Shariatifar B, Motamedi N, Abdolahi H. Comparison of liver enzymes level and sonographic findings value with liver biopsy findings in nonalcoholic fatty liver disease patients. Adv Biomed Res 2016; 5: 40.
[http://dx.doi.org/10.4103/2277-9175.178785] [PMID: 27099853]
[21]
Friedman LS, Dienstag JL, Watkins E, et al. Evaluation of blood donors with elevated serum alanine aminotransferase levels. Ann Intern Med 1987; 107(2): 137-44.
[http://dx.doi.org/10.7326/0003-4819-107-2-137] [PMID: 3111321]
[22]
Barker J, Horn EJ, Lebwohl M, et al. International Psoriasis Council. Assessment and management of methotrexate hepatotoxicity in psoriasis patients: report from a consensus conference to evaluate current practice and identify key questions toward optimizing methotrexate use in the clinic. J Eur Acad Dermatol Venereol 2011; 25(7): 758-64.
[http://dx.doi.org/10.1111/j.1468-3083.2010.03932.x] [PMID: 21198946]
[23]
Sakthiswary R, Chan GY, Koh ET, Leong KP, Thong BY. Methotrexate-associated nonalcoholic fatty liver disease with transaminitis in rheumatoid arthritis. Sci World J 2014; 2014823763
[http://dx.doi.org/10.1155/2014/823763] [PMID: 24971392]

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