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PubMedDate not supplied

Methotrexate in Crohn's disease: results of a randomized, double-blind, placebo-controlled trial.

BACKGROUND/AIMS: Immunosuppression with methotrexate may be useful in the treatment of Crohn's disease. We tested the efficacy of methotrexate in refractory Crohn's disease in a randomized, controlled trial. METHODOLOGY: Randomized, double-blind placebo-controlled trial of methotrexate in 33 patients with steroid-dependent Crohn's disease, 33% of whom had previously failed therapy with 6-mercaptopurine. Patients were given placebo or oral methotrexate 15 mg/week, or adjusted up to 22.5 mg/week, for up to 1 year or until treatment failure. Outcome was assessed by reduction in prednisone dosage, Crohn's Disease Activity Index, hospital admission, and laboratory parameters. RESULTS: Four patients were dropped from the study for non-compliance and one because of intercurrent illness, and 28 patients could be evaluated. Fewer methotrexate-treated patients (6/13 or 46%) had flares of Crohn's disease as compared to placebo-treated patients (12/15 or 80%), but this did not achieve statistical significance (p<0.1). There was a non-significant trend toward an increased number of significant side effects in the methotrexate-treated patients (3/13 or 23%) as compared to the placebo-treated patients (0/15 or 0%) (p<0.2). Laboratory indices of inflammation did not differ between the two groups. CONCLUSIONS: The methotrexate-treated group showed a trend toward fewer Crohn's disease flares, balanced by an increased number of significant side effects.

Administration, Oral↗

PubMed1976

Treatment of acute lymphocytic leukemia by high-dose intravenous methotrexate.

A pharmacokinetic study of methotrexate levels in blood and cerebrospinal fluid was performed in 42 patients who received one or more courses of high-dose methotrexate at 500 mg/sq m infused i.v. over a 24-hr period. Methotrexate level in the lumbar cerebrospinal fluid reached 1.2 x 10(-7) M at 0.5 hr and remained constant at that level for the 1st 24 hr. Similar methotrexate levels were noted in the ventricular fluid obtained through an Ommaya device on three patients with brain tumors treated with high doses of methotrexate. Preliminary clinical results using high-dose methotrexate combined with simultaneous intrathecal methotrexate in 23 children with newly diagnosed acute lymphocytic leukemia indicate that this treatment program is safe to administer and to date appears effective in the prevention of central nervous system leukemia.

Brain Neoplasms↗

PubMed1975

Tissue-specific synthesis of methotrexate polyglutamates in the rat.

Purified tritium-labeled methotrexate was administered to rats and Sephadex G-15 gel chromatography was used to study the formation of poly-gamma-glutamyl metabolites of methotrexate in different tissues. These metabolities were recognized as tritium-labeled antifolate fractions and were identified by their response to serum pterolypolyglutamate hydrolases and by cochromatography with authentic standards. After doses equivalent to 15 to 20 mg for man, rat liver and kidney were found to contain both 4-amino 10-methylpterolyglutamyl-gamma-glutamic acid and 4-amino-10-methylpterolyglutamyl-gamma-glutamyl-gamma-glutamic acid. With one-third of the dose, only 4-amino 10-methylpteroylglutamyl-gamma-glutamic acid was found. Synthesis of methotrexate polyglutamates in liver and kidney was limited to the interval immediately following methotrexate administration and appeared to occur by sequential addition of single glutamyl residues to so-called "free" intracellular methotrexate. No synthesis of methotrexate polyglutamates was demonstrated in small intestine or thymus. After formation, 4-amino-10-methylpteroyglutamyl-gamma-glutamic acid disappeared from liver and kidney with a half-time of 6.5 days. The effect of these metabolites of methotrexate of cell metabolism is unknown.

Animals↗

PubMed2003

Methotrexate pneumonitis in a patient with rheumatoid arthritis.

Methotrexate pneumonitis is an unpredictable and life-threatening side effect of methotrexate therapy. Early diagnosis, cessation of methotrexate, and treatment with corticosteroids and/or cyclophosphamide are important in the management of patients with methotrexate pneumonitis. Methotrexate pneumonitis has not been reported in patients of Chinese ethnicity. We report a case of methotrexate pneumonitis in a Taiwan patient with rheumatoid arthritis who presented with acute nonproductive cough, dyspnea, fever, severe hypoxemia, and rapid progression to respiratory failure. Chest roentgenogram demonstrated bilateral diffuse interstitial and alveolar infiltration. Thoracoscopic biopsy with wedge resection of the upper lobe of the right lung was performed and the histologic findings of the biopsy specimen were consistent with bronchiolitis obliterans with organizing pneumonia. Rapid improvement of methotrexate pneumonitis was achieved after pulse therapies of methylprednisolone and cyclophosphamide and daily use of prednisolone.

Antirheumatic Agents↗

PubMedDate not supplied

[Managing methotrexate toxicity: a case report].

High-dose methotrexate is included in chemotherapy regimens used to treat a number of malignant neoplasms. Methotrexate plasma concentration is considered the best toxicity predictor. Monitoring methotrexate plasma concentrations is standard practice in the identification of at-risk patients, the titration of folinic acid doses, and the establishment of corrective measures. Methotrexate is a kidney-cleared weak acid, and renal function impairment may retard methotrexate clearance. A case of severe methotrexate-induced toxicity secondary to renal failure is reported in a patient with non-Hodgkin s lymphoma receiving methotrexate at a dose of 1 g/m2. Corrective measures included folinic acid rescue therapy, cholestyramine resin administration, hydration and urine alkalinization, urine pH monitoring, and extracorporeal clearance techniques.

Acute Kidney Injury↗

PubMed2005

[Psoriatic arthritis: combined treatment with prospidin and methotrexate].

AIM: To compare clinical efficacy of methotrexate monotherapy and methotrexate combination with prospidin in patients with psoriatic arthritis (PA). MATERIAL AND METHODS: Sixty three patients (42 females and 21 males) with documented PA, generalized articular syndrome of the second-third degree of activity were divided into two groups. Patients of group 1 (n = 30) received combined therapy (i.v. prospidin 200-300 mg/week + i.m. methotrexate 10 mg/week). Maintenance consisted of prospidin in a dose 100-200 mg/week i.m., methotrexate dose was the same. Patients of group 2 (n = 33) were given methotrexate monotherapy in a dose 10 mg/ week i.m. RESULTS: In the first three months of the study and in maintenance therapy, combined treatment was more effective. By ACR criteria, 50-70% response was achieved after 12 months of treatment in 44 and 27.3% patients of groups 1 and 2, respectively. The number of side effects and drug-related withdrawals was 23.3 and 36.4%, 10 and 15.1% in groups 1 and 2, respectively. CONCLUSION: Combination of methotrexate with prospidin produced an earlier and more potent positive clinical effect than methotrexate alone in PA patients.

Adult↗

PubMed1991

Methotrexate and histologic hepatic abnormalities: a meta-analysis.

STUDY OBJECTIVE: To determine the risk of liver toxicity from the long-term administration of methotrexate in patients with rheumatoid arthritis or psoriatic arthritis. DESIGN: A meta-analysis of 15 studies examining the relationship between long-term, low-dose methotrexate administration and biopsy evidence of liver fibrosis. PATIENTS: A total of 636 patients from 15 studies. RESULTS: The incidence of progression of liver disease (defined as worsening of at least one grade on the histologic classification of Roenigk) among 636 patients was 27.9% (95% confidence intervals 24.3 to 31.6). The rate of progression of liver disease in the 15 studies was associated with the cumulative dose of methotrexate (p = 0.01). Patients on average had a 6.7% (95% confidence intervals 2.1 to 11.4) chance of progressing at least one histologic grade on liver biopsy for each gram of methotrexate taken. The overall incidence of advanced pathologic changes on liver biopsy (grades IIIB or IV) among 636 patients was 5.0% (95% confidence intervals 3.5 to 7.0). The development of advanced histologic changes was not associated with the cumulative dose of methotrexate (p = 0.08). Patients who according to their history were heavy drinkers (at least 100 g of alcohol per week) were more likely to have advanced changes on liver biopsy (17.8% versus 4.5%, p = 0.0003) and to show histologic progression (73.3% versus 25.9%, p = 0.0002). Patients with psoriasis were more likely than patients with rheumatoid arthritis to have advanced changes (7.7% versus 2.7%, p = 0.003) and histologic progression (33.1% versus 24.3%, p = 0.02). CONCLUSIONS: The risk of liver toxicity in patients undergoing long-term, low-dose methotrexate therapy is substantial, and that risk increases with the total cumulative dose and with heavy consumption of alcohol. Heavy users of alcohol should not receive long-term methotrexate therapy. For most patients who are not heavy users of alcohol, liver biopsies should be done periodically to monitor for the occurrence of liver toxicity.

Alcohol Drinking↗

PubMed1988

Impaired polyglutamylation of methotrexate as a cause of resistance in CCRF-CEM cells after short-term, high-dose treatment with this drug.

Two methotrexate-resistant sublines, CCRF-CEM R3/7 and CCRF-CEM R30/6, were selected from the human leukemia T-lymphoblast cell line, CCRF-CEM, after repeated exposures (7 and 6 times, respectively) for 24 h to constant concentrations (3 and 30 microM) of the drug. Analysis of the mechanism of resistance revealed no differences in levels of dihydrofolate reductase activity, its binding affinity for methotrexate, or in methotrexate transport between the CCRF-CEM parent and methotrexate-resistant cell lines. The development of resistance to methotrexate was associated with a marked decrease in the intracellular level of methotrexate polyglutamates. Although the resistant sublines were able to form substantial amounts of folate polyglutamates when measured with [3H]folic acid, the level of polyglutamates formed was decreased to about 50% of that formed by the parent cell line. No qualitative differences in folate polyglutamates formed were noted between the parental and resistant sublines. This is the first example of a cell line which displays resistance which is solely attributable to defective methotrexate polyglutamate synthesis.

Drug Resistance↗

PubMed1988

Pharmacokinetics of small doses of methotrexate in patients with psoriasis.

The pharmacokinetics of methotrexate was studied in 23 patients with chronic plaque psoriasis. Ten patients received a single oral does and 13 patients a single intramuscular injection of 25 mg methotrexate. Serum methotrexate was measured for 24 hours following administration of the drug using a magnetizable solid-phase radio-immunoassay. The disappearance of methotrexate from the serum fitted a two-compartment model with a distribution phase half-life of 1.18 +/- 0.12 h and an elimination phase half-life of 5.35 +/- 0.62 h following the oral dose and 1.45 +/- 0.22 h and 4.71 +/- 0.32 h, respectively following the intramuscular dose. Peak serum methotrexate concentrations varied greatly between patients but the mean area below the curve for the two routes of administration did not differ significantly. In a further 18 psoriatic patients receiving long-term maintenance methotrexate therapy there was no consistent relationship between salivary and serum methotrexate levels.

Administration, Oral↗

PubMedDate not supplied

Intestinal epithelium regeneration in rats receiving methotrexate and a trial of regulating this regeneration with pentagastrin and glucagon.

The study was carried out in three groups of rats: group I of 36 rats received methotrexate, group II of 36 rats were given methotrexate, pentagastrin and glucagon, group III of 12 rats served as control. For histological examination the ileum was taken from the animals killed on days 1, 2, 3, 4, 7 and 9 after the last injection of methotrexate. Besides histological examinations the mitotic index and the number of cells in crypt longitudinal-section were determined. Relatively low doses of methotrexate caused characteristic changes in the intestinal mucosa: disappearance of mitotic figures, shortening of crypts particularly on the first day after the last dose of methotrexate. On the following days regeneration processes were noted causing an excessive epithelial proliferation observed up to the 9th day after the last dose of methotrexate. This indicates that the mobilized mechanisms of epithelial proliferation stimulation exert their effect fairly long. In the group receiving methotrexate administration of pentagastrin and glucagon contributed to the increased number of mitoses in crypt epithelium and the number of cells on crypt longitudinal-section. These observations are an evidence of a beneficial effect of the hormones administered to the rats in the regeneration of the ileal epithelium damaged by the cytostatic agent.

Animals↗

PubMed1989

Folate and methotrexate interactions in the rat kidney.

The mechanisms controlling the renal retention and urinary output of methotrexate and folates were studied in rats. 125I-Labeled folic acid administered i.v. was shown to be retained in the kidney through a system that could be inhibited by either folic acid or 5-methyltetrahydrofolate. Methotrexate also inhibited this system but required concentrations 50- to 100-fold greater than that required for folic acid and 5-methyltetrahydrofolate. Extracts from solubilized kidneys were shown to contain a folate binder with the same relative affinities for folates and methotrexate as the in vivo system. Methotrexate was shown to cause an increase in the urinary output of endogenous folates in rats when administered as equivalent doses to those used in treating human disease. Conversely, [3H]methotrexate administered i.v. was shown to be retained in the kidney through an additional system that could be inhibited by unlabeled methotrexate, but not by folates. This system was not demonstrable in solubilized kidney. These data demonstrate two systems for the renal retention of methotrexate.

Animals↗

PubMed1989

Topical methotrexate therapy for psoriasis.

In vitro percutaneous penetration of methotrexate is enhanced with 1-dodecylazacycloheptan-2-one (laurocapram [Azone]). Laurocapram-containing methotrexate formulations provide effective local inhibition of epidermal DNA synthesis in the in vivo hairless mouse and minipig models, providing the biochemical rationale for topical use in the treatment of psoriasis. Topical methotrexate (0.1%, 0.5%, and 1%) in a laurocapram-containing formulation was tested in a two-center double-blind pilot clinical study of 42 patients with plaque psoriasis. Drugs were applied twice a day for six weeks, and lesions were scored weekly for erythema, scale, and elevation. An overall improvement of 50% or more in the combined scores for erythema, scale, and elevation was obtained with 0.1% methotrexate (64% of patients), 0.5% methotrexate (59%), and 1% methotrexate (56%) vs the vehicle alone (25%). These preliminary findings suggest that methotrexate preparations that provide adequate percutaneous absorption may have a beneficial effect in the treatment of psoriasis.

Administration, Topical↗

PubMed1978

Optimization of high-dose methotrexate with leucovorin rescue therapy in the L1210 leukemia and sarcoma 180 murine tumor models.

An analysis of dose and schedule dependence of calcium leucovorin rescue during high-dose methotrexate therapy of ascitic forms of l1210 leukemia and Sarcoma 180 is reported. Schedules with very delayed "low-dose" leucovorin rescue following lethal doses of methotrexate were highly effective in preventing toxicity and achieved a pronounced antitumor effect in both ascites tumor models. Best results were obtained on a schedule of methotrexate (400 mg/kg s.c.) followed 16 to 20 hr later by calcium leucovorin (12 mg/kg s.c.) given once every 2 hr for a total of 5 doses. Progressive increases in the calcium leucovorin dosage on any schedule reduced both toxicity and the antitumor effect of methotrexate in each model. Following a single course of therapy, essentially no toxicity was observed, and the antitumor effects were 2-fold (L1210 leukemia) and 4-fold (Sarcoma 180) greater than a single, maximally tolerated dose (24/kg s.c.) methotrexate alone. An increase in the methotrexate dosage to 800 mg/kg s.c. with or without an increase in calcium leucovorin dosages on the same schedule did not appreciably increase the antitumor effect observed. Two courses of high-dose methotrexate (400 mg/kg s.c.) with leucovorin rescue (24 mg/kg s.c. 16, 20, and 24 hr after drug) given with an 8-day interval between courses doubled the total antitumor effect in each model with no substantial increase in toxicity and gave long-term survivors with Sarcoma 180. The results, overall, are in close agreement with prior prediction for schedule and dose dependence made on the basis of related pharmacokinetic and biochemical studies in murine tumor models reported from this laboratory.

Animals↗

PubMed1988

A randomized controlled trial of parenteral methotrexate compared with sodium aurothiomalate (Myochrysine) in the treatment of rheumatoid arthritis.

Forty patients with rheumatoid arthritis (RA) were enrolled in a double blind study of 26 weeks duration designed to compare the efficacy and safety of parenteral methotrexate and sodium aurothiomalate (GSTM) in the treatment of RA. All the patients had active RA and none had previously received gold, D-penicillamine or immunosuppressive therapy. Patients were randomized to receive weekly intramuscular (IM) injections of either methotrexate 10 mg or GSTM 50 mg. Two patients taking methotrexate and 7 taking GSTM were withdrawn before 26 weeks. Methotrexate was as effective as GSTM as measured by numbers of swollen or tender joints, morning stiffness, grip strength, pain scale and erythrocyte sedimentation rate. Five patients taking methotrexate and 11 taking GSTM presented side effects (p = 0.05). Total number of adverse reactions was 5 for the methotrexate group and 15 for the GSTM group (p less than 0.01). Our data suggest that low dose IM methotrexate is less toxic and as effective as GSTM for the treatment of RA during the first 6 months of therapy.

Adult↗

PubMed1987

The aminopyrine breath test, an inadequate early indicator of methotrexate-induced liver disease in patients with psoriasis.

The aminopyrine breath test has been shown to be a sensitive noninvasive indicator of liver cell dysfunction. In a search for a noninvasive method of monitoring the effects of methotrexate therapy, we have investigated the use of the aminopyrine breath test in patients receiving methotrexate for the treatment of severe psoriasis. The [14C]-aminopyrine breath test was performed in 20 normal control subjects, 32 patients with psoriasis receiving methotrexate therapy, and 8 patients with histologically confirmed cirrhosis of differing etiology. Eighteen patients on methotrexate had liver biopsies classified as grade I changes, 6 patients as grade II, and 8 patients as grade III. The normal value for the breath test was 11.0 +/- 1.6% (mean +/- 1 SD). The mean [14C]-CO2 excretion (8.3 +/- 4.4%) of the 8 patients with grade III liver disease was significantly different from the control subjects (p less than 0.02), and those with grade I liver changes (p less than 0.04). The aminopyrine breath test was only able to detect the later severe stages of methotrexate hepatotoxicity, grade III, when fibrosis occurs, before established cirrhosis was present. Our data suggests that the aminopyrine breath test is not a sensitive indicator for the detection of early methotrexate-induced hepatotoxicity, (stages I and II), but will detect the precirrhotic stage III change. Consequently, we recommend that a liver biopsy should be performed annually in all psoriatic patients receiving methotrexate, to detect histological damage, especially when the aminopyrine breath test score falls below the 95% confidence limits of normal.

Aminopyrine↗

PubMed1986

Pharmacokinetic interactions of cyclophosphamide and 5-fluorouracil with methotrexate in an animal model.

In tumor-bearing WAG/Rij rats the interaction of cyclophosphamide and/or 5-fluorouracil (5-FU) with methotrexate as manifested at the pharmacokinetic level was studied. Four groups were formed of at least ten animals. The control group, which received single-agent methotrexate, was compared with groups that received methotrexate plus cyclophosphamide, methotrexate plus 5-FU, and methotrexate plus cyclophosphamide plus 5-FU. There appeared to be an increase of 40% in the clearance of methotrexate by the triple combination. Cyclophosphamide especially diminished the terminal part of the concentration-time curve of methotrexate.

Animals↗

PubMed1985

Clearance studies of methotrexate in dogs after multiple-rate infusion.

Plasma, renal, and nonrenal clearances of methotrexate as well as their interrelationship were studied in five conditioned male beagle-mongrel dogs using the multiple-rate infusion method. Steady-state plasma methotrexate concentrations of 1, 20, and 100 micrograms/ml were targeted for by i.v. bolus doses followed by i.v. infusions. An isotonic solution of sodium bicarbonate or ammonium chloride was simultaneously infused to study the effect of acid-base imbalance on the clearances. NaCl solution (0.9%) infusion served as a control. Plasma and urine concentrations of methotrexate were quantitated by a sensitive high-performance liquid chromatographic method. Distortion of body acid-base balance did not significantly change the clearances of methotrexate. The results showed that the plasma clearance (4.02 to 4.68 ml/min/kg) of methotrexate was relatively constant over the concentration range studied. The renal and nonrenal clearances, on the other hand, were concentration dependent. As the plasma methotrexate concentration increased from 1 to 20 or 100 micrograms/ml, renal clearance decreased from 3.60 to 4.28 ml/min/kg to 2.62 to 2.73 ml/min/kg, and nonrenal clearance increased form 0.35 to 0.42 ml/min/kg to 1.38 to 1.74 ml/min/kg. Concentration-dependent renal clearance may be due to saturation of the process involving active tubular secretion of methotrexate.

Animals↗

PubMed1984

Transport routes utilized by L1210 cells for the influx and efflux of methotrexate.

Routes which contribute to the transport of methotrexate across the plasma membrane of L1210 cells have been evaluated. A single high affinity transport system was found to be the only route for methotrexate uptake. This conclusion was derived from the observations that influx at high substrate concentrations (up to 50 microM) both reaches a single maximum value and can be inhibited by greater than 98% either by treatment of the cells with an active ester of methotrexate or by the direct addition of excess amounts of competitive inhibitors. Efflux, conversely, could be separated into three components. One of these routes was dependent upon extracellular anions and could be blocked by active ester treatment and, therefore, appeared to be the same transport system which mediates methotrexate influx. A second route was identified by its sensitivity to bromosulfophthalein, while a third component was insensitive to both active ester treatment and to bromosulfophthalein. When these efflux routes were quantitated in a buffered saline medium, the methotrexate influx carrier was found to account for the major portion (71%) of total efflux. The inhibitor-insensitive component contributed an additional 23%, while the remaining 6% was attributable to the bromosulfophthalein-sensitive route. The addition of glucose increased total efflux by 3-fold and caused a substantial change in the proportion of efflux that occurred via each of the three components. The major portion of efflux (46%) now occurred via the bromosulfophthalein-sensitive route, while the influx carrier contributed only 29% of the total. The inhibitor-insensitive route accounted for the remaining 25%. The opposite result was obtained with metabolic inhibitors which decreased total efflux but increased the contribution by the influx carrier to greater than 80%. The demonstration of multiple routes for methotrexate efflux and their differential sensitivities to alterations in energy metabolism thus provides a basis for explaining previously described asymmetries between the influx and efflux of methotrexate in mouse leukemia cells.

Animals↗