GUIDELINES - MTX therapy for RA: clinical practice guidelines

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Joint Bone Spine. 2006 Jul;73(4):388-95. Epub 2006 Mar 23.

Methotrexate therapy for rheumatoid arthritis: clinical practice

guidelines based on published evidence and expert opinion.

Pavy S, Constantin A, Pham T, Gossec L, Maillefert JF, Cantagrel A,

Combe B, Flipo RM, Goupille P, Le Loët X, Mariette X, Puéchal X,

Schaeverbeke T, Sibilia J, Tebib J, Wendling D, Dougados M.

Service de rhumatologie A, CHU Cochin, 27, rue du

Faubourg-Saint-Jacques, 75014 Paris, France.

OBJECTIVES: To develop clinical practice guidelines for the use of

methotrexate in rheumatoid arthritis (RA), using the evidence-based

approach and expert opinion. METHODS: A scientific committee used a

Delphi procedure to select five questions, which formed the basis for

developing recommendations. Evidence providing answers to the five

questions was sought in the Cochrane databases, PubMed, and

proceedings of meetings of the French Society for Rheumatology,

European League Against Rheumatism, and American College of

Rheumatology. Using this evidence, a group of rheumatologists

developed and validated the recommendations. For each recommendation,

the level of evidence and the extent of agreement among experts were

specified.

RESULTS: The recommendations were as follows:

1: The starting dosage for methotrexate in patients with RA should not

be less than 10 mg/week and should be determined based on disease

severity and patient-related factors;

2: When a patient with RA shows an inadequate response to

methotrexate, the dosage should be increased at intervals of 6 weeks,

up to 20 mg/week, according to tolerance and patient-related factors;

3: When starting methotrexate treatment in a patient with RA,

preference should be given to the oral route. A switch to the

intramuscular or subcutaneous route should be considered in patients

with poor compliance, inadequate effectiveness, or gastrointestinal

side effects;

4: At present, there is no evidence indicating that a change in

methotrexate dosage is in order when a TNF antagonist is given

concomitantly;

5: The investigations that are mandatory before starting methotrexate

therapy in a patient with RA consist of a full blood cell count, serum

transaminase levels, serum creatinine with computation of creatinine

clearance, and a chest radiograph. In addition, serological tests for

the hepatitis viruses B and C and a serum albumin assay are

recommended. In patients with a history of respiratory disease or

current respiratory symptoms, lung function tests with determination

of the diffusing capacity for carbon monoxide are recommended;

6: Investigations that are mandatory for monitoring methotrexate

therapy in patients with RA consist of full blood cell counts and

serum transaminase and creatinine assays. These tests should be

obtained at least once a month for the first 3 months then every 4-12

weeks;

7: Folate supplementation can be given routinely to patients treated

with methotrexate for RA. In practice, a minimal dosage of 5 mg of

folic acid once a week, at a distance from the methotrexate dose, is

appropriate;

8: In the event of respiratory symptoms possibly related to

methotrexate toxicity, the drug must be stopped and symptom severity

evaluated. Should evidence of serious disease be found, the patient

should be admitted immediately or advice from a pulmonologist should

be obtained immediately.

CONCLUSION: Recommendations about methotrexate therapy for RA were

developed. These recommendations should help to improve practice

uniformity and, ultimately, to improve the management of RA.

PMID: 16626993

http://www.ncbi.nlm.nih.gov/pubmed/16626993

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