Methotrexate in psoriasis: a systematic review of treatment modalities, incidence, risk factors and monitoring of liver toxicity

Abstract

Based on expert experience, the starting dose of MTX is between 5 and 10 mg/week for the first week. Fast dose escalation is recommended in order to obtain a therapeutic target dose of 15-25 mg/week. The maximum recommended dose is 25 mg/week. A folic acid supplement is necessary. The initiation of treatment by oral administration is preferred. In cases where inadequate response is obtained or in the event of poor gastrointestinal tolerance, subcutaneous dosing can be proposed at the same dose. Published data do not confirm the incidence of hepatic fibrosis. Type 2 diabetes and obesity appear to be significant risk factors in fibrosis. A combination of FibroTests and fibroscans together with measurement of the type III serum procollagen aminopeptide seem to be ideal method for monitoring liver toxicity.

Acute Severe Methotrexate Toxicity in Patients with Psoriasis: A Case Series and Discussion

“…The mortality associated with the use of MTX in patients with psoriasis is low, with a death rate of 1.2 per 100,000 patients treated with MTX every year, and it is mostly due to pancytopenia [6]. Although there seems to be an important under-reporting of severe adverse events, data from long-term studies in psoriasis suggest that MTX is a safe drug when used at weekly low-dose regimens [4,5]. …”

“…It is considered a safe drug when prescribed at regimens not exceeding 25 mg/week [4,5], but adequate selection and monitoring of patients is fundamental to prevent toxicity, which is potentially lethal [6]. We report herein four consecutive patients with psoriasis who developed acute MTX toxicity in the last 5 years, and we review the factors that can contribute to acute MTX toxicity.…”

Psoriasis and Obesity

“…In fact, studies have shown that, in overweight patients with psoriasis treated with MTX, obesity is a greater risk factor for hepatotoxicity than viral hepatitis, alcohol, and cumulative dose of MTX. Steatosis of the liver probably adds to the risk, and therefore liver transaminases should be monitored more closely in these patients [59][60][61] . Little is known about the effect of obesity on the response to treatment with MTX, but 1 study showed that loss of response over time was more likely in obese patients treated with MTX [62] .…”

An unusual case of acute methotrexate toxicity manifesting as ulcers on psoriatic plaques in an elderly male

“…3 Treatment guidelines on the use of MTX in psoriasis have been published by Roenigk et al in 1973, 4 1982, 5 1998 6 and updated by a group of experts from the United States National Psoriasis Foundation in 2009. 7 Absolute or relative overdose of methotrexate can result in acute toxicity, manifested clinically by myelosuppression, mucosal ulceration (especially oral), and rarely cutaneous necrolysis.…”