REVIEW - Gradual methotrexate escalation best in RA therapy

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Gradual Methotrexate Escalation Best in RA Therapy

NEW YORK (Reuters Health) Jul 08 - The findings from a literature

review suggest that methotrexate therapy for rheumatoid arthritis (RA)

should start at low oral doses and subcutaneous administration should

be reserved for those who do not respond adequately, Dutch researchers

report in the July issue of ls of the Rheumatic Diseases.

Drs. K. Visser and D. van der Heijde of Leiden University Medical

Center point out that the agent " is effective, has an acceptable

toxicity profile and has low costs. " However, " considerable

variability exists in the way rheumatologists prescribe methotrexate

therapy, including the dosage and route of administration. "

To shed more light on the matter, the researchers identified and

reviewed data from 38 relevant randomized controlled trials. Of these

studies, 8 provided level 1b-2b evidence for the efficacy and toxicity

of various dosages and routes of methotrexate delivery.

The team found that starting with high oral doses of methotrexate or

escalating rapidly to high doses (25 to 30 mg per week) was associated

with a better clinical effect but also more gastrointestinal adverse

events.

Starting with 15 mg per week subcutaneous administration led to a

higher clinical efficacy than did the oral route of administration.

However, withdrawal because of toxicity was also more common in

patients with early RA.

Altogether, the researchers recommend that patients start on oral

methotrexate 15 mg per week and escalate at 5 mg per month to 25 or 30

mg or to the highest tolerable dose. If the response is inadequate,

they recommend a subsequent switch to subcutaneous administration.

Ann Rheum Dis 2009;68:1094-1099.

http://www.medscape.com/viewarticle/705572

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