Cytotoxic drugs for non-neoplastic disease.

Ansell, Gary; Evans, Srt; Jackson, C T; Lewis-Jones, Sue

doi:10.1136/bmj.287.6394.762-a

Cited by 12 publications

(2 citation statements)

References 3 publications

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“…When the drug was stopped the pain regressed and the fracture healed. To our knowledge Ansell et al for the first time drew attention to the occurrence of stress fractures as a possible complication of MTX treatment for non-neoplastic diseases 8. Since then several case reports including patients treated for psoriasis and rheumatic diseases have been published 9-15…”

Section: Discussionmentioning

confidence: 99%

Stress fracture in long term methotrexate treatment for psoriatic arthritis

Wijnands

Burgers

2001

Annals of the Rheumatic Diseases

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Stress fracture in long term methotrexate treatment for psoriatic arthritis M Wijnands, A BurgersCase history A 42 year old woman presented at the outpatient rheumatology department with severe, incapacitating pain of her left leg. There was no previous trauma. The patient did not recall fever or malaise.Psoriasis had been diagnosed at age 17 years. Initially, topical drugs were prescribed. Periodically etretinate, a synthetic analogue of retinoid acid, and photochemotherapy were prescribed as additional treatment. The patient did not receive cyclosporin. Oligoarthritis of her knees and ankles first appeared at an age of 25 years. Management with non-steroidal antiinflammatory drugs and sporadically an intraarticular injection of corticosteroids was adequate to control the symptoms. At age 37 a severe polyarthritis of elbows, wrists, finger joints, ankles, and metatarsophalangeal joints developed. Treatment with methotrexate (MTX) was started at an initial dose of 7.5 mg weekly, resulting in a good clinical response. Two years later the dosage was gradually increased to 20 mg weekly because of a flare.On examination there was little pretibial oedema with tenderness of the distal tibia, especially at the lateral margin. There was an active arthritis of the left knee, wrists, metacarpophalangeal and proximal interphalangeal joints. A cardiorespiratory examination was unremarkable and the patient was afebrile. Laboratory investigations showed a slight increase in erythrocyte sedimentation rate of 20 mm/1st h. Full blood count, renal and hepatic function, creatine kinase, calcium, serum protein electrophoresis, thyroid stimulating hormone, parathyroid hormone, and vitamin D were all normal. Urine analysis was negative.Standard anteroposterior and lateral x ray pictures showed no abnormalities on either tibia or fibula. Technetium-99m ( 99m Tc) scintigraphy disclosed a longitudinal hot spot in the middle third of the tibia on the left (fig 1). Computed tomography showed a clear longitudinal fissure with minimal displacement and starting callus formation (fig 2). Bone mineral density (BMD) measured by dual x ray absorptiometry of the lumbar spine and femoral neck showed no manifest osteoporosis.Treatment was started with a Sarmiento brace. As an MTX related stress fracture was considered, the MTX dosage was tapered to 7.5 mg weekly and within weeks the symptoms of the left tibia evanesced. Unfortunately, the arthritis symptoms flared and an intramuscular injection of a depot corticosteroid was given. A few months later pain on weight bearing emerged in the right foot. Repeated bone scintigraphy showed a normal left tibia, but new lesions in the right midfoot and the fifth rib at the right. An x ray examination showed a fracture of the 2nd and 3rd metatarsal bone and of

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Section: Discussionmentioning

confidence: 99%

Stress fracture in long term methotrexate treatment for psoriatic arthritis

Wijnands

Burgers

2001

Annals of the Rheumatic Diseases

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“…MTX is a cytotoxic drug commonly used at low dosage as a disease modifying drug in rheumatologic diseases, mainly in rheumatoid arthritis (RA) [2] and psoriasis [3]. A case of MTX induced osteopathy in rheumatology was firstly described in 1983, in a 72 years Caucasian man treated for widespread skin psoriasis and psoriatic arthritis; he developed spontaneously a stress fracture of the medial condyle of the right femur [4]. After this case, many cases, mostly isolated cases reports, were reported in the literature.…”

Section: Introductionmentioning

confidence: 99%

Methotrexate osteopathy: five cases and systematic literature review

et al. 2020

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Methotrexate concentrations in synovial membrane and trabecular and cortical bone in rheumatoid arthritis patients

Bologna

Edno

Anaya

et al. 1994

Arthritis & Rheumatism

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Objective. To determine methotrexate (MTX) concentrations in the synovial membrane (SM) and cortical and trabecular bone of rheumatoid arthritis (RA) patients.Methods. Ten RA patients (9 women, 1 man; mean +. SD age 49.2 f 10.6, mean disease duration 13.2 f 9.9 years) undergoing surgical procedures for rheumatoid articular lesions participated in this study. Mean +. SD MTX treatment duration was 26.4 f 21.3 months. The day preceding surgery, 10 mg of MTX was administered intramuscularly. During surgery, a mean & SD of 19.7 f 2.6 hours after MTX administration, SM, bone fragments, and blood were collected simultaneously. MTX was assayed by fluorescence polarization immunoassay in plasma and tissues.Results. The mean f SD plasma concentration was 0.0252 +-0.01 nmoles/ml at the time of tissue sampling. The mean MTX concentration in SM was 0.285 & 0.159 nmoledgm. The mean MTX concentrations in trabecular and cortical bone were 0.292 f 0.164 and 0.286 f 0.126 nmoledgm, respectively.Conclusion. After intramuscular administration, high MTX concentrations are found in SM and cortical and trabecular bone of RA patients.

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Cytotoxic drugs for non-neoplastic disease.

Cited by 12 publications

References 3 publications

Stress fracture in long term methotrexate treatment for psoriatic arthritis

Stress fracture in long term methotrexate treatment for psoriatic arthritis

Methotrexate osteopathy: five cases and systematic literature review

Methotrexate concentrations in synovial membrane and trabecular and cortical bone in rheumatoid arthritis patients

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