E007 Is there an urgent need to change the methotrexate monitoring guidelines to incorporate fibroscan?

Abstract

Background/Aims Methotrexate (MTX) is a widely used DMARD for which routine blood monitoring is required to identify hepatotoxicity and bone marrow suppression. Despite routine monitoring and normal liver function tests some patients develop hepatic fibrosis. Transient elastography (fibroscan) offers an excellent non-invasive approach to measure the stiffness of the liver as a form of assessing hepatic fibrosis and would prove extremely useful to monitor the effects of MTX in our patient groups. Methods A retrospective study was conducted between January 2021 and August 2022. Inflammatory arthritis patients who have been on MTX for more than five years were selected for the study. Their fibroscan results were obtained and their median value (kilopascals), if they had an ultrasound in the past showing cirrhosis, metabolic risk factors such as obesity (BMI>30), presence of type 2 diabetes and alcohol consumption (>14 units/week) were recorded from their clinic letters. Results Of the 56 patients, there were 18 males and 38 females. 29% of the patients had a median fibroscan value of more than 7 kpa (n = 16). Of these 16 patients, 50% of the patients had a metavir score of F2 (n = 8), 25% of the patients had a metavir score of F3 (n = 4) and 25% of the patients had a metavir score of F4 (n = 4). Of the 16 patients (11 RA and 5 PSA) with high median value, 46% had a BMI > 30 kg/m2 (n = 7), 13% had a diagnosis of type 2 diabetes mellitus (n = 2) and none of the patients had consumed more than 14 units/week of alcohol. Of the 16 patients with high median value, 12% (n = 2) had a diagnosis of cirrhosis on ultrasound. One patient had extremely high median value of 26 had underlying ILD, right heart failure and possible cardiac cirrhosis. 1 patient had developed frank cirrhosis and the high fibroscan results were noted subsequently. For all the patients with high metavir score of F4 and above, MTX therapy was discontinued. Conclusion A significant percentage of the cohort (29%) had a high median value above 7 of which 25% of the patients had F4 fibrosis despite having normal liver function tests. The study illustrates the need for a different modality in addition to the routine blood monitoring for the patients on MTX with metabolic risk factors. Therefore, it is vital to obtain a baseline fibroscan in high-risk patient group with preexisting metabolic risk factors prior to initiating MTX therapy and monitor every 5 years thereafter. This will help the clinician to safely continue MTX in this group of patients without the fear of worsening liver fibrosis. Disclosure S. Ramalingam: None. M. Sayed: None. S. Alam: None. D. Makkuni: None.