A randomized, controlled trial of methotrexate versus placebo in early diffuse scleroderma

Abstract

Objective Early diffuse scleroderma (systemic sclerosis; SSc) has no proven treatment. This study was undertaken to examine the efficacy of methotrexate (MTX) in improving the skin and other disease parameters in early diffuse SSc. Methods Seventy‐one patients with diffuse SSc of <3 years' duration were enrolled in a multicenter, randomized, placebo‐controlled, double‐blind trial. Thirty‐five patients were treated with MTX and 36 with placebo. Treatment was administered for 12 months. The primary outcome measures were skin score (as determined with 2 different indices) and physician global assessment. Results At baseline, there were no statistically significant differences in skin scores, carbon monoxide diffusing capacity (DLCO), physician global assessment, or other secondary outcome measurements between the 2 treatment groups. At study completion, results slightly favored the MTX group (mean ± SEM modified Rodnan skin score 21.4 ± 2.8 in the MTX group versus 26.3 ± 2.1 in the placebo group [P < 0.17]; UCLA skin score 8.8 ± 1.2 in the MTX group versus 11.0 ± 0.9 in the placebo group [P < 0.15]; DLCO in the MTX group 75.7 ± 4.6 versus 61.8 ± 3.4 in the placebo group [P < 0.2]). In addition, physician global assessment results favored MTX (P < 0.035), whereas patient global assessment did not differ significantly between groups. When between‐group differences for changes in scores from baseline to 12 months were examined using intent‐to‐treat methodology, MTX appeared to have a favorable effect on skin scores (modified Rodnan score −4.3 in the MTX group versus 1.8 in the placebo group [P < 0.009]; UCLA score −1.2 in the MTX group versus 1.2 in the placebo group [P < 0.02]), but differences in the degree of change in the DLCO and physician global assessment were not significant. For the UCLA skin score, these differences in results were not statistically significant after adjustment for baseline differences in sex distribution and steroid use. Dropout rates were similar in the 2 groups. Conclusion Although results of this trial demonstrated a trend in favor of MTX versus placebo in the treatment of early diffuse SSc, the between‐group differences were small and the power to rule out false‐negative results was only 50%. Our findings do not provide evidence that MTX is significantly effective in the treatment of early diffuse SSc.

Recombinant human anti–transforming growth factor β1 antibody therapy in systemic sclerosis: A multicenter, randomized, placebo‐controlled phase I/II trial of CAT‐192

“…In contrast trials of potential overall disease-modifying strategies in SSc have been disappointing. Immunomodulatory agents that have been evaluated include chlorambucil, methotrexate, and extracorporeal photopheresis (7)(8)(9). Putative antifibrotic or matrix-altering agents tested in SSc have included D-penicillamine, interferon-␣, ketanserin, and recombinant human relaxin (10)(11)(12)(13).…”

Relationship between change in skin score and disease outcome in diffuse cutaneous systemic sclerosis: Application of a latent linear trajectory model

“…Despite these limitations, several studies have demonstrated that treatment with immunosuppressive agents, compared with placebo, resulted in statistically significant improvement in the MRSS in patients with early dcSSc (6)(7)(8). Thus, the skin score may be influenced by treatment, but the demonstration of this effect is likely to be hampered by spontaneous improvement.…”

Bayesian Inference: Statistical Gimmick or Added Value?

“…Raw data from a clinical trial in SSc suggested a beneficial treatment effect of methotrexate on skin score 5 . However, due to the small numbers of patients recruited into the trial and to limited power, the investigators had to correctly conclude that there was insufficient evidence to reject the null hypothesis of no treatment effect.…”