ReviewMethotrexate use in rheumatoid arthritis. A clinician's perspective
Section snippets
Efficacy
Regardless of what is the preferred name for compounds such as methotrexate (MTX) (disease modifying anti-rheumatic drugs (DMARDs), second-line agents or slow-acting anti-rheumatic drugs), MTX is an anti-folate which has proven to be efficacious for the treatment of rheumatoid arthritis (RA), as demonstrated by the initial four randomized clinical trials (RCTs) included in Tugwell's meta-analysis as well as in publications reporting on cohorts of patients followed for months and even years. In
Toxicity
Early in the 1980s, toxicity was recognized as the major factor limiting the use of this compound Gispen et al., 1987, Alarcón et al., 1989. It was also recognized that some of the toxic manifestations, especially those occurring immediately after MTX administration (such as abdominal discomfort, alopecia, oral ulcerations and cytopenias), resembled complicated folate-deficiency resulting from the inhibition of dihydrofolic acid reductase (Baggott et al., 1993); the possibility that the
Doses, route and monitoring
MTX is administered weekly in a single oral dose or divided in two doses taken 12 h apart American College of Rheumatology AD HOC Committee in Clinical Guidelines, 1996, Alarcón, 1997. Folic acid can be safely administered prior to the initiation of MTX and while baseline hematological and chemical profiles are being obtained American College of Rheumatology AD HOC Committee in Clinical Guidelines, 1996, Alarcón, 1997. B12 levels and hepatitis serologies are also indicated. A chest radiograph
Methotrexate in other inflammatory disorders
The list of conditions for which MTX has been utilized is vast and includes diseases affecting different organ systems treated by a number of different specialists. Pulmonologists have used it for the treatment of severe sarcoidosis Lower and Baughman, 1990, Toews and Lynch, 1990, and asthma (Mullarkey et al., 1988); gastroenterologists for inflammatory bowel disorder and idiopathic granulomotous hepatitis Kozarek et al., 1989, Feagan et al., 1995, Knox et al., 1995; dermatologists for
Acknowledgements
To Ella Henderson for her most expert assistance in the preparation of this manuscript.
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