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Clinical liver disease in patients with rheumatoid arthritis taking methotrexate
C A Phillips1, P J Cera, T F Mangan
1Department of Rheumatology, Geisinger Medical Center, Danville, PA 17822.
Abstract:
Between 1981 and 1989, 3 of 134 patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) developed clinically significant hepatic dysfunction and showed histologic evidence of severe liver disease (fibrosis and cirrhosis). Factors identified in these patients that may have been linked to liver toxicity included diabetes, congestive heart failure and Felty's syndrome. In the patient group that received a post-MTX liver biopsy, pulmonary fibrosis and obesity were significantly associated with hepatic fibrosis/cirrhosis. Severe liver disease may occur in patients with RA treated with low dose MTX (less than 3%). Early liver biopsy is recommended in selected cases.
Insights
Methotrexate (MTX) can cause severe liver disease, including fibrosis and cirrhosis, in rheumatoid arthritis patients. Conditions like diabetes, heart failure, pulmonary fibrosis, and obesity may increase this risk, warranting early liver biopsy in some cases.
Area of Science:
- Rheumatology
- Hepatology
- Clinical Pharmacology
Background:
- Methotrexate (MTX) is a common disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis (RA).
- While effective, MTX carries potential risks, including hepatic toxicity.
- Monitoring liver function is crucial for patients on long-term MTX therapy.
Observation:
- A retrospective study analyzed 134 RA patients treated with MTX between 1981 and 1989.
- Three patients (2.2%) developed significant liver dysfunction and histological evidence of severe liver disease (fibrosis, cirrhosis).
- Associated comorbidities in affected patients included diabetes, congestive heart failure, and Felty's syndrome.
Findings:
- In patients undergoing liver biopsy post-MTX, pulmonary fibrosis and obesity were significantly associated with hepatic fibrosis/cirrhosis.
- Severe liver disease occurred even with low-dose MTX (under 3mg/week).
- These findings highlight specific risk factors for MTX-induced hepatotoxicity in RA.
Implications:
- Clinicians should consider comorbidities like diabetes, heart failure, pulmonary fibrosis, and obesity when prescribing MTX for RA.
- Early liver biopsy may be beneficial for selected RA patients on MTX exhibiting risk factors or concerning symptoms.
- This underscores the importance of vigilant monitoring and risk stratification in MTX therapy for rheumatoid arthritis.