#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Optimization of methotrexate treatment in rheumatoid arthritis therapy


Authors: K. Pavelka
Authors‘ workplace: Revmatologický ústav Praha
Published in: Čes. Revmatol., 28, 2020, No. 1, p. 16-22.
Category: Review Article

Overview

The aim of this review is to assess the position of methotrexate (MTX) in a modern strategy for the treatment of active rheumatoid arthritis. It has been noted that MTX is not used adequately in routine clinical practice, neither in frequency, dose and possible forms of administration. As recommended by EULAR (European League Against Rheumatism), MTX should always be part of the first treatment strategy. It can also be an anchor drug when other synthetic or biological drugs are added to MTX in case of inadequate response. More recently, the combination of MTX with glucocorticoids has been shown to be beneficial in initiating treatment for early rheumatoid arthritis. The dose of 10 mg MTX per week with rapid titration to 25–30 mg per week is recommended as an initial dose. With rapid dose escalation, up to 40% of patients can achieve low disease activity status. MTX is always given in combination with folic acid. The problem of oral MTX is non-constant absorption, especially at doses higher than 15 mg per week. It is, therefore, preferable to switch to subcutaneous administration of MTX. A meta-analysis of 7 studies showed greater efficacy of subcutaneous MTX than oral. Subcutaneous administration also results in a faster onset of action. It has also been shown that switching to subcutaneous MTX can reduce the need for biological treatment by up to 20%, making it a pharmacologically advantageous procedure. Subcutaneous MTX is currently available, with autoinjectors in the form of pre-filled pens being particularly preferred.

Keywords:

Methotrexate – rheumatoid arthritis – subcutaneous methotrexate


Sources

1. Alamanos Y, Drossos AA. Epidemiology of adult rheumatoid arthritis. Autoimmune Rev 2005; 4: 130–136.

2. Smolen J, Breedveld FC, Burmestr G, et al. Treating rheumatoid arthritis to target: 2014 update of the international task force. Ann Rheum Dis 2017; 76: 960–977.

3. Smolen J, Landewe R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update Ann Rheum Dis 2016; 75: 3–15.

4. Singh JA, Saag KG, Bridges S. ACR Guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2016; 678: 1–25.

5. Wasko MC, Dasgupta A, Hubert H, et al. Propensity – adjusted association of methotrexate with overall survival in rheumatoid arthritis. Arthritis Rheum 2013; 65: 334–342.

6. Emery P, Breedveld FC, Lemmel EM, et al. A comparison of the efficacy and safety of leflunomide and methotrexate in the treatment of rheumatoid arthritis. Rheumatology (Oxford) 2000; 69: 1004–1009.

7. Moreland LW, O Dell JR, Paulus HER, et al. A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: the treatment of Early Aggressive Rheumatoid Arthritis Trial. Arthritis Rheum 2012; 64: 2824–2835.

8. Nam JL, Villeneuve E, Hensor EM, et al. Remission induction comparing infliximab and high-dose intravenous steroid followed by treat-to-target: a double blind, randomized, controlled trial in new onset, treatment naive, rheumatoid arthritis (IDEA study) Ann Rheum Dis 2014; 63: 75–85.

9. Verschueren P, De Cock D, Corluy L, et al. Methotrexate in combination with other DMARD sis not superior to MTX alone for remission induction with moderate to high glucocorticoid bridging in early RA after 16 months treatment, The Care RA trial. Ann Rheum Dis 2015; 74: 27–34.

10. Visser K, van der Heijde D. Optimal dosage and route of administration of methotrexate in rheumatoid arthritis: a systematic review of the literature. Ann Rheum Dis 2009; 68: 1094–1099.

11. Emery P, Bingham CO, Burmester G, et al. Certolizumab pegol in combination with dose-optimised methotrexate in DMARD naive patients with early, active rheumatoid arthritis with poor prognostic factors: 1 year results from C-EARLY, a randomized, double–blind, placebo–controlled phase III study. Ann Rheum Dis 2017; 76: 96–104.

12. Schiff MH, Jaffe JS, Freundlich B. Head to head, randomized, crossover study of oral versus subcutaneous MTX in patients with rheumatoid arthritis: drug – exposure limitations of oral MTX at doses15 mg may be overcome with subcutaneous administration. Ann Rheum Dis 2014; 73: 1549–1551.

13. Schiff MH, Sadowski P. Oral to subcutaneous MTX dose conversion strategy in the treatment of rheumatoid arthritis. Rheumatol Int 2017; 37: 213–218.

14. Braun J, Kastner P, Flaxcnberg P, et al. Comparison of clinical efficacy and safety of sc MTX vs oral administration of MTX in patients with active RA. Results of a six months, multicentre, randomized, double blind, controlled, phase IV trial. Arthritis Rheum 2008; 58: 73–81.

15. Bianchi G, Caporali R, Todoenti M, et al. Methotrexate and rheumatoid arthritis: current evidence regarding subcutaneous versus oral routes of administration. Adv Ther 2016; 33: 369–378.

16. Li D, Yang Z, Kang P. Subcutaneous administration of methotrexate at high doses makes a better performance in the treatment of rheumatoid arthritis compared with oral administration of methotrexate: a systematic review and metaanalysis. Semin Arthritis Rheum 2016; 45: 656–662.

17. O’Connor A, Thome C, Kang, H et al. The rapid kinetics of optimal treatment with subcutaneous MTX in early inflammatory arthritis: observational study. BMC Musculoscelet Disord 2016; 17: 364.

18. Vena GA, Cassano N, Iannone F. Update on subcutaneous methotrexate for inflammatory arthritis and psoriasis. Ther Clin Risk Management 2018; 14: 105–116.

19. Scott DG, Claydon, P, Ellis C. Retrospective evaluation of continuation rates following a switch to subcutaneous MTX in rheumatoid arthritis patients failing to respond to or tolerate oral MTX: MENTOR study. Scand J Rheumatol 2014; 43: 470–476.

20. Klein A, Kaul I, Foeldvari I, et al. Efficacy and safety of oral and parenteral MTX therapy in children with JIA: an observational study with patients from German MTX Registry Arthritis Care Res (Hoboken) 2012; 64: 1349–1356.

21. Koduri GM, Mukhtyar C. Why subcutaneous methotrexate should be a prerequisite to biologic use in patients with rheumatoid arthritis. Rheumatology (Oxford) 2019; 58: 559–560.

22. Rohr MK, Mikuls TR, Cohen SB, et al. Underuse of MTX in the treatment of rheumatoid arthritis. A national analysis of prescribing practices in the US. Arthritis Care Res 2017; 69: 794–800.

23. McKeage K, Lyseng-Willliamson K. Methotrexate in prefilled autoinjector pen for subcutaneous use. Profile its use in EU. Drugs Ther Perspect 2018; 34: 197–202.

24. Saraux A, Hudry Ch, Zinovieva E, et al. Use of auto-injector for methotrexate subcutaneous self-injections: high satisfaction level and good compliance in SELF-I study, a randomized, open-label, parallel group study. Rheumatol Ther 2019; 6: 47–60.

25. Homer Dawn. Using video-based training for button-free auto-injection of subcutaneous methotrexate: A pilot study. Musculoskeletal Care 2019; 17: 247–279.

Labels
Dermatology & STDs Paediatric rheumatology Rheumatology
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#