Methotrexate pneumonitis precipitated by switching from oral to parenteral administration

Collins, Kelsey; Aspey, H.; Todd, Adam; Saravanan, Vadivelu; Rynne, M.; Kelly, Clive

doi:10.1093/rheumatology/kem230

Cited by 7 publications

(4 citation statements)

References 4 publications

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“…The most common noninfectious pulmonary complication is AIP, with uncommon reports of interstitial fibrosis, nodules, asthma, and air trapping. 16,[119][120][121][122][123][124][125] Importantly, MTX has been associated with progression of preclinical interstitial disease, 63 raising the issue of screening and avoidance of MTX in certain patients. However, this is a rare occurrence and with the high prevalence of minor abnormalities and the significant benefit of MTX, a decision as to whether to avoid the drug or not should be based on both the severity of the joint disease and underlying lung disease.…”

Section: Nonbiologic Dmardsmentioning

confidence: 99%

“…Acute pneumonitis may be an idiosyncratic reaction, as it does not always recur on rechallenge with MTX. Pneumonitis can occur with low doses (< 20 mg per week), usually within 2 years but can begin early after commencement and on changing from oral to parenteral, 120 or in one case, a month after it was discontinued. In patients with RA, the overall likelihood of developing acute pneumonitis during MTX therapy is 0.3 to 11.6%.…”

Section: Nonbiologic Dmardsmentioning

confidence: 99%

“…147 In terms of disease control and reduction in corticosteroid use, the use of bDMARDS outweigh the risk of infection with these drugs. 53,150 With respect to corticosteroids in RA, it is estimated a dose of 5 mg/d is associated with a RR for severe infection of 1.4 (95% CI, 1.2, 1.6), for 5 to 10 mg/day a RR of 1.9 (95% CI, 1.7, 2.2), and for 10 to 20 mg/ day a RR of 3.0 (95% CI, 1.9, 4.7), 23,54,119,120 so minimizing the dose should be a priority.…”

Section: Infection In Rheumatoid Arthritismentioning

confidence: 99%

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Rheumatoid Arthritis and Lung Disease: From Mechanisms to a Practical Approach

Lake

Proudman

2014

Semin Respir Crit Care Med

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Rheumatoid arthritis (RA) is a common chronic systemic autoimmune disease characterized by joint inflammation and, in a proportion of patients, extra-articular manifestations (EAM). Lung disease, either as an EAM of the disease, related to the drug therapy for RA, or related to comorbid conditions, is the second commonest cause of mortality. All areas of the lung including the pleura, airways, parenchyma, and vasculature may be involved, with interstitial and pleural disease and infection being the most common problems. High-resolution computed tomography of the chest forms the basis of investigation and when combined with clinical information and measures of physiology, a multidisciplinary team can frequently establish the diagnosis without the need for an invasive biopsy procedure. The most frequent patterns of interstitial lung disease (ILD) are usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP), with some evidence for the prognosis being better than for the idiopathic equivalents. Risk factors depend on the type of disease but for ILD (mainly UIP and NSIP) include smoking, male gender, human leukocyte antigen haplotype, rheumatoid factor, and anticitrullinated protein antibodies (ACPAs). Citrullination of proteins in the lung, frequently thought to be incited by smoking, and the subsequent development of ACPA appear to play an important role in the development of lung and possibly joint disease. The biologic and nonbiological disease modifying antirheumatic drugs (DMARDs) have had a substantial impact on morbidity and mortality from RA, and although there multiple reports of drug-related lung toxicity and possible exacerbation of underlying ILD, overall these reactions are rare and should only preclude the use of DMARDs in a minority of patients. Common scenarios facing pulmonologists and rheumatologists are addressed using the current best evidence; these include screening the new patient; monitoring and choosing RA treatment in the presence of subclinical disease; treating deteriorating ILD; and establishing a diagnosis in a patient with an acute respiratory presentation.

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Section: Nonbiologic Dmardsmentioning

confidence: 99%

Section: Nonbiologic Dmardsmentioning

confidence: 99%

Section: Infection In Rheumatoid Arthritismentioning

confidence: 99%

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Rheumatoid Arthritis and Lung Disease: From Mechanisms to a Practical Approach

Lake

Proudman

2014

Semin Respir Crit Care Med

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“…It reportedly occurred in one patient within 6 weeks of initiating MTX treatment and slowly resolved after its discontinuation [49]. In another patient switching from oral to subcutaneous administration seemed to initiate pneumonitis [50]. There is no evidence that MTX worsens interstitial lung disease in RA patients [51].…”

Section: Long-term Safety Of Methotrexatementioning

confidence: 99%

An update on methotrexate

Braun

Rau

2009

Current Opinion in Rheumatology

121

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When should we use parenteral methotrexate?

et al. 2010

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Oral methotrexate is the benchmark against which other disease-modifying anti rheumatic drugs are measured. The use of parenteral methotrexate for those failing to tolerate or respond to oral therapy is accepted, but indications for its use and its place in the therapeutic ladder have not been fully investigated. We assessed the use of parenteral methotrexate (MTX) in our rheumatoid arthritis (RA) population and compared the characteristics of these patients to a matched group of those on oral therapy. We compared response rates to each approach using DAS 28 scores, ESR and visual analogue scales. Inferences on costs of parenteral therapy were made and predictors of response defined. We found that 10% of our total RA patient population were on parenteral methotrexate, having failed to tolerate or respond to oral therapy. Seventy-five percent of these met the criteria for the use of anti-tumour necrosis factor (TNF) agents. Overall response rates were equivalent to those obtained by responders to oral MTX. Patients on parenteral therapy were younger and were more likely to have extreme values of body mass index (BMI) than those on oral therapy. The approach was economically viable, although many patients unnecessarily attended hospital to receive their injections. We advocate consideration of parenteral MTX in all RA patients unresponsive to oral therapy prior to treatment with anti-TNF therapy. Response to parenteral therapy can be predicted by low BMI (below 22 kg/m(2)), possibly as a result of malabsorption, or by high BMI (over 30) as a result of gastrointestinal intolerance. A mechanism to deliver this option through self-administration in the community should be encouraged.

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Methotrexate pneumonitis precipitated by switching from oral to parenteral administration

Cited by 7 publications

References 4 publications

Rheumatoid Arthritis and Lung Disease: From Mechanisms to a Practical Approach

Rheumatoid Arthritis and Lung Disease: From Mechanisms to a Practical Approach

An update on methotrexate

When should we use parenteral methotrexate?

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