Methotrexate-Related Liver Cirrhosis in Psoriatic Arthritis: A Case Report and Review of the Literature

Abstract

Methotrexate is an anchor-drug for the treatment of inflammatory arthritides affecting peripheral joints, such as rheumatoid and psoriatic arthritis (PsA), but also for other immune-mediated diseases like psoriasis. Although it is generally a well-tolerated drug, adverse effects often occur. Reversible derangement of liver function test is the most common laboratory adverse event. However, in some cases, liver cirrhosis and/or fibrosis can occur. Besides, many of these diseases like PsA and psoriasis are closely linked with clinical conditions and risk factors that also contribute to liver damage/cirrhosis, such as increased body mass index, dyslipidaemia and diabetes mellitus (DM). It has been hypothesised that the aforementioned risk factors along with methotrexate usage can act synergistically, causing liver damage in these patients. Herein, we describe a PsA patient with DM who developed fatal liver cirrhosis after 10 years of treatment with MTX. We also review the literature about the liver toxicity of MTX in the context of PsA and psoriasis, describing concurring risk factors and histopathological findings. PubMed and Scopus were searched, without date limits. The keywords “methotrexate” AND “psoriatic arthritis” OR “psoriasis” AND “Liver damage” OR “liver fibrosis” OR “cirrhosis” were used. We found that although fibrosis/cirrhosis is present in about 10–25% of the patients, MTX can rarely cause liver damage itself. However, it can exert its effect when other factors, like increased alcohol consumption and obesity coexist. Prospective studies are needed, specifically examining the hepatotoxicity of MTX in individuals with immune-mediated diseases.

MRI Findings in Axial Psoriatic Spondylarthritis

“…Its long-term use has been related to severe liver toxicity, hepatic fibrosis, and eventually liver cirrhosis, although those findings only included old studies based on individuals who received a high dose administered daily. Newer studies have shown that MTX rarely induces liver fibrosis per se, but rather it acts synergistically with other hepatotoxic factors, such as diabetes mellitus or metabolic syndromes including obesity, increased body mass index, and dyslipidemia, which are strongly associated with PsA, or alcohol consumption [ 122 ].…”

“…Newer techniques such as MRE may help with the further follow-up of patients undergoing biological and non-biological treatments to evaluate treatment hepatotoxicity, as it showed a higher success rate and diagnostic accuracy than Fibroscan, with comparable results to liver biomarkers [ 122 , 123 , 124 ]. Further studies on a larger population are necessary to validate the actual data.…”