Use of methotrexate in patients with inflammatory bowel diseases

Methotrexate (MTX) is one of the immunosuppressants commonly used in inflammatory bowel diseases. There is very good evidence for its use in patients with steroid-dependent or steroid-refractory Crohn's disease for induction as well as maintenance of remission. Optimal dose as well as mode of application is still a matter of debate. The only large randomised controlled trials used 25 mg/wk for induction and 15 to 25 mg/wk for maintenance of remission, both applied intramuscularly. Current guidelines recommend methotrexate in patients with extensive disease, steroid-refractory, and steroid-dependent disease. They even suggest MTX for patients with infrequent relapses in the need of repetitive corticosteroid therapy. In clinical practice it is mainly used in patients who failed treatment with thiopurines (azathioprine or 6-mercaptopurine) or who are intolerant to these drugs. MTX can also be used in paediatric patients, whereas the evidence for its effectiveness in fistulising disease is very weak. Two small studies did not prove that MTX is efficacious in ulcerative colitis. Even though case series suggest otherwise, its use is not recommended by current guidelines for patients with ulcerative colitis.