Tuesday, July 8, 2014

Methotrexate at the EULAR 2014 Meeting in Paris

Methotrexate (MTX) is an old drug, but at the same time it remains a most interesting drug, which still retains quite a lot of secrets. If you search the abstracts for MTX you find a plethora of studies mentioning the drug. It turned out to be difficult not to discard too many studies and yet keep the following text focussed on issues specific for the EULAR 2014 Meeting. # indicates the Number in the abstract book.

Adherence / patient compliance
    Not only for MTX adherence is presently a hot topic.
Most frequently reported reasons for noncompliance with MTX were forgetting or not remembering to take it. #OP0004
    Abstract #THU0130 also ponted out: unintentional omission of MTX doses was the main reason for non-adherence.
    Nearly half of patients with MTX reported less than perfect compliance with MTX. #OP0004 [Less is more! I wouldn't make a fuss if MTX is omitted every now and then. Less is more means: physicians aren't gaining anything in making their patients feel guilty.]
    Reducing treatment burden, may improve patient compliance. #OP0004
    Patients on etanercept and MTX had greater adherence and persistence than those on triple therapy. #THU0441 [Easy to agree with, but one has to make such a study to prove the hypothesis. And it doesn't men the end of triple therapy as there are enough patients with contraindications to biologics.]
    Treatment at hospital or in private practice did not influence the adherence to MTX. #FRI0183

Oral versus subcutaneous MTX
    Use of injectable MTX was associated with a significantly longer duration of MTX monotherapy compared with oral MTX. #THU0115
    Rheumatoid arthritis patients with an inadequate response to oral MTX maintained satisfactory disease control when switched to subcutaneous MTX. #THU0111
    Efficacy of SC MTX therapy is associated with reduced proinflammatory cytokines, chemokines and growth factor. #THU0110
    SC MTX is effective and well-tolerated in rheumatois arthritis patients. 50% didn’t need addition of biologics. St. Gallen Cohort Early RA. #THU0140
    [I come from a center, where oral MTX is used less than subcutaneous MTX. We start MTX SC and might switch to oral MTX later. We encourage our patients to switch to oral MTX in the same dosage during holidays and switch back to SC after their return.]
    GEMS (The Guildford Evaulation of Methotrexate Subcutaneous) audit suggests that there is added benefit of switching patients to SC MTX at the same dose. # AB0457

    Patients with early rheumatoid arthritis under MTX require much less biologics than patients with long-standing rheumatoid arthritis. #THU0160
    Early therapeutic intervention with MTX in patients with undifferentiated arthritis prevents development rheumatoid arthritis. #THU0249
    Response more often in patients with early arthritis in whom start of MTX is driven by the 2010 ACR/EULAR criteria than by the 1987 ACR criteria. #FRI0041
SC MTX monotherapy allowed to achieve LDA or remission in the vast majority of rheumatoid arthritis patients with good response to treatment. #THU0160
    Parenteral MTX is associated with improved survival over oral MTX for initial treatment in patients with rheumatoid arthritis. #THU0255
    SC MTX has better efficacy and tolerability than in oral MTX, if there is inefficacy or intolerability due to GIS side effects. #AB0473
    Higher cumulative use of MTX / trad. DMARDs within the 1st year after RA diagnosis is associated with less joint replacements. #THU0120
    Compared to oral MTX repeated intra-articular MTX injections show a quicker suppression of knee synovitis. #SAT0364
    The combination of leflunomide plus MTX was effective in the majority of rheumatoid arthritis patients and is a cost-effective. #AB0456
    Patients with polymyositis and dermatomyositis do not significantly benefit from upfront MTX addition to glucocorticoids. #OP0289
    Methotrexate should be consideres in GCA patients with severe corticosteroid-related side effects / prolonged corticosteroid therapy. #SP0004

Adverse events
    There hasn't been much on adverse events; maybe because we think we know these side effects well enough.
Only 14% of rheumatois arthritis patients developed macrocytosis after conversion from oral to SC MTX. #AB0458
    None of the patients (any Autoimmune Inflammatory Rheumatic Disease - AIIRD) developed MTX pneumonitis and only one had ILD related to RA. N=43 (!) #AB0459

Hope you stayed through these condensed results on methotrexate.

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