Hepatic effects of long-term methotrexate use in the treatment of inflammatory bowel disease

Te, Helen S.; Schiano, Thomas D.; Kuan, Shih Fan; Hanauer, Stephen B.; Conjeevaram, Hari S.; Baker, Alfred L.

doi:10.1016/s0002-9270(00)02080-3

Cited by 50 publications

(29 citation statements)

References 35 publications

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“…Risk factors for methotrexate hepatotoxicity include obesity, presence of diabetes mellitus, a prior history of excessive or long-term ethanol use, elevated baseline hepatocellular laboratory chemistries, a cumulative dose of methotrexate exceeding 1.5 g total drug dose, and daily dosing of methotrexate (138) . e risk of methotrexate liver toxicity in patients with CD who do not have one or more of these risk factors is low (139) . Prior to initiation of therapy with methotrexate, a liver biopsy is appropriate for patients with abnormal baseline liver chemistries, patients with one or more risk factors for hepatotoxicity, and patients who are suspected of having baseline chronic liver disease.…”

Section: Moderate To Severe Diseasementioning

confidence: 99%

“…Prior to initiation of therapy with methotrexate, a liver biopsy is appropriate for patients with abnormal baseline liver chemistries, patients with one or more risk factors for hepatotoxicity, and patients who are suspected of having baseline chronic liver disease. e need to perform a repeat liver biopsy once a cumulative dose in excess of 1.5 g is reached has not been formally assessed in controlled clinical trials in patients with in ammatory bowel disease, as the risk of methotrexate-induced hepatotoxicity in patients without known risk factors is low (139) . In the absence of adequate biopsy data from patients with CD, it is recommended that the American Rheumatology Association guidelines regarding surveillance for hepatic toxicity be followed (140) .…”

Section: Moderate To Severe Diseasementioning

confidence: 99%

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Management of Crohn's Disease in Adults

2009

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Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifi cally valid research, derived from extensive review of published literature. When data that will withstand objective scrutiny are not available, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be fl exible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are infl exible and rarely violated. Given the wide range of choices in any health-care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. Expert opinion is solicited from the outset for the document. The quality of evidence upon which a specifi c recommendation is based is as follows: Grade A: Homogeneous evidence from multiple well-designed randomized (therapeutic) or cohort (descriptive) controlled trials, each involving a number of participants to be of suffi cient statistical power. Grade B: Evidence from at least one large well-designed clinical trial with or without randomization, from cohort or case -control analytic studies, or well-designed meta-analysis. Grade C: Evidence based on clinical experience, descriptive studies, or reports of expert committees. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fi elds. The fi nal recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientifi c developments at a later time.

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Section: Moderate To Severe Diseasementioning

confidence: 99%

Section: Moderate To Severe Diseasementioning

confidence: 99%

Management of Crohn's Disease in Adults

2009

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“…All patients should be prescribed folic acid 1mg daily as it significantly reduces hepatic toxicity, an infrequent occurrence, and gastrointestinal toxicity associated with MTX [34,35] . At present, our target population for MTX are CD patients who are unable to tolerate azathioprine or 6Mercaptopurine due to adverse events, homozygous TMPT mutations, or inefficacy.…”

Section: Practical Advice On How To Prescribe Mtx In the Usmentioning

confidence: 99%

Use of methotrexate in inflammatory bowel disease in 2014: A User’s Guide

Swaminath¹

2014

WJGPT

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Methotrexate has been used an immunomodulator in many autoimmune diseases, including inflammatory bowel disease. However, many physicians are unfamiliar or uncomfortable with its use in the management of inflammatory bowel disease. We summarize the data for use of methotrexate in common clinical scenarios: (1) steroid dependant Crohn's disease (CD); (2) maintenance of remission in steroid free CD; (3) azathioprine failures in CD; (4) in combination therapy with Anti-TNF agents in CD; (5) decreasing antibody formation to Anti-TNF therapy in CD; (6) management of fistulizing disease in CD; and (7) as well as induction and maintenance of remission in ulcerative colitis. An easy to use algorithm is provided for the busy clinician to access and safely prescribe methotrexate for their inflammatory bowel disease patients.

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“…The risk of cirrhosis is directly related both to the cumulative exposure to methotrexate as well as the presence of other risk factors for liver disease. 21 Therefore, patients with a history of excessive alcohol use and nonalcoholic fatty liver risk factors (eg, diabetes, obesity, hyperlipidemia) should avoid methotrexate. 21 Elevated aminotransferase levels do not always correlate with the presence of hepatic fibrosis, and a liver biopsy should be considered if there is reasonable clinical suspicion for hepatic fibrosis, particularly if the cumulative dose has exceeded 1.5 g. 21 Methotrexate has high abortifacient and teratogenic effects, and patients should be counseled appropriately.…”

Section: Side Effectsmentioning

confidence: 99%

Advanced Therapy for Inflammatory Bowel Disease: A Guide for the Primary Care Physician

Thomas

Lodhia

2014

The Journal of the American Board of Family Medicine

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Primary care physicians care for patients with inflammatory bowel disease (IBD) who are receiving advanced therapies that include immunomodulator drugs (eg, azathioprine and methotrexate) and biologic therapy. These agents have significantly improved remission rates and the quality of life for patients suffering from IBD. However, patients taking these drugs need special care and counseling with regard to adverse effects, infection risk, cancer risk, and pregnancy. Newer treatment paradigms incorporate earlier use of biologic therapy, often in combination with immunomodulator drugs, to alter the natural course of the disease. Comprehensive care for these patients, including health maintenance, requires collaboration between primary care physicians and gastroenterologists. Despite their high cost, advanced therapies are likely to be cost-effective. This article discusses general concepts about azathioprine, 6-mercaptopurine, methotrexate, and common biologic drugs used in IBD. ( J Am Board Fam Med 2014;27:411-420.)

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Hepatic effects of long-term methotrexate use in the treatment of inflammatory bowel disease

Cited by 50 publications

References 35 publications

Management of Crohn's Disease in Adults

Management of Crohn's Disease in Adults

Use of methotrexate in inflammatory bowel disease in 2014: A User’s Guide

Advanced Therapy for Inflammatory Bowel Disease: A Guide for the Primary Care Physician

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