“The current treatment paradigm for rheumatoid arthritis should not change based on these data,” he adds.
Shaye Kivity, MD, of The Chaim Sheba Medical Center, Ramat-Gan, Israel, who has studied the toxicity of low-dose methotrexate used in systemic inflammatory disease, says the new research “emphasizes the need for tight surveillance in patients treated with methotrexate. Yet it should be noted that the patients in this study were not the same patients we treat in our daily practice with methotrexate. We treat patients with immune-mediated rheumatic disease, and they benefit from immunosuppression.”
“Clinicians should be encouraged to continue to use methotrexate, and patients should not be intimidated,” he tells Reuters Health by email. “Under the supervision of an experienced clinician and careful monitoring, life-threatening adverse effects are exceedingly rare.”
“Symptomatic adverse effects that are often most concerning to patients with rheumatoid arthritis and inflammatory arthritis include alopecia, nausea, malaise, and diarrhea,” writes Vivian P. Bykerk, MD, of the Hospital for Special Surgery and Weill Cornell Medical College, New York, in a linked editorial.2 “Given their subjective nature, these were not separately addressed in this study. Over 3 decades of methotrexate use in rheumatoid arthritis and inflammatory arthritis, strategies to minimize these effects also include coprescription of folinic acid, split methotrexate dosing and switching to parenteral methotrexate.”
“These data provide objective estimates of risk for adverse effects, reminding us that methotrexate use has inherent risks and warrants vigilance for symptomatic, laboratory, and infrequent but clinically serious adverse effects—particularly skin cancer and hepatic, pulmonary, and hematologic toxicity,” she says. “The authors of this preplanned safety analysis from the CIRT study should be commended for providing estimates of adverse effects that can inform improved systematic monitoring of patients using methotrexate.”
References
- Solomon DH, Glynn RJ, Karlson EW, et al. Adverse effects of low-dose methotrexate: A randomized trial. Ann Intern Med. 2020 Feb 18. [Epub ahead of print]
- Bykerk VP. A call to systematically monitor for adverse events in users of low-dose methotrexate therapy. Ann Intern Med. 2020 Feb 18. [Epub ahead of print]
