Update on subcutaneous methotrexate for inflammatory arthritis and psoriasis

Abstract

Methotrexate (MTX) is one of the mainstays of treatment for several immune-mediated inflammatory joint and skin diseases, especially rheumatoid arthritis (RA) and moderate-to-severe psoriasis. Oral MTX has been used for the treatment of such diseases for decades for many reasons. There is, however, a relevant interpatient variability of clinical and safety outcomes that can also be related to differences in patients’ individual pharmacogenomic profile. Orally administered MTX has been found to have a saturable intestinal absorption and nonlinear pharmacokinetics, with significant consequences on drug bioavailability and clinical efficacy. The current evidence shows that parenterally administered MTX results in rapid and complete absorption, higher serum levels, and less variable exposure than oral dosing. The use of parenteral MTX, particularly when administered as a subcutaneous (SC) injection, has recently raised great interest in order to overcome the limitations of oral MTX. The effectiveness and safety of SC MTX have mostly been assessed in rheumatological settings, especially in patients with RA. There are only a limited number of data on SC MTX in juvenile idiopathic arthritis and even fewer in psoriatic disease. Various clinical experiences have suggested that SC MTX is more effective than oral MTX and may provide significant benefit even in patients in whom oral MTX proved to be inadequate. The increased efficacy of SC MTX resulting from higher drug exposure compared with oral MTX has been associated with a similar safety profile and in various reports even with a lower frequency of gastrointestinal complaints. The aim of this article was to review the available literature data on SC MTX treatment of inflammatory arthritis, with special emphasis on RA and psoriasis, examining differences with oral MTX treatment. A brief mention of pharmacokinetics, pharmacodynamic features and pharmacoeconomic considerations is also given.

Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature

“…GI symptoms [ 20 , 24 , 40 , 112 ], including nausea [ 23 , 26 , 27 , 40 ], vomiting [ 23 , 40 ] and abdominal discomfort [ 23 ], are associated with long-term methotrexate therapy. Subcutaneous or intramuscular methotrexate administration may overcome some of the limitations of oral therapy regarding GI symptoms; however, to date no studies have directly compared these two routes of administration in patients with psoriasis [ 125 ]. Dose reductions of methotrexate may help to avoid GI symptoms and the addition of folic acid to the therapeutic regimen is also helpful, although high doses of folic acid can diminish the therapeutic effect of methotrexate [ 108 ].…”

The role of microbiome in rheumatoid arthritis treatment

“…Among DMARDs, MTX is a widely used drug and has emerged as the preferred orally active agent for initial therapy of RA. 70 It is derived from the parent compound aminopterin. Initially, aminopterin was used to treat childhood leukemia, but its ability to inhibit proliferation of connective tissue led to its use in RA.…”

Exploratory Assessment of Oxygen Flow–Assisted Cutaneous Administration of Methotrexate for Superficial Basal Cell Carcinoma, Mycosis Fungoides, and Extramammary Paget Disease

“…Unfortunately, the oral administration of MTX has potential severe adverse effects, including liver and/or renal insufficiency, dyspnea, leukopenia, anemia, restrictive pneumopathy, myelosuppression, toxic mucous reactions, fatigue, muscle weakness, and so forth. Subcutaneous administration of MTX improves gastrointestinal tolerance but does not reduce the risk of the other adverse effects (Nguyen and Banga, 2018;Vena et al, 2018).…”