Methotrexate Hepatotoxicity in Rheumatoid Arthritis: An Analysis of the Physicians' Policy

Methotrexate hepatotoxicity could be a reason for the discontinuation or dose reduction in patients with Rheumatoid Arthritis (RA); however, the consequence of different policies in this situation is unclear and the physicians need to know what would happen after their decision.

To demonstrate the consequence of multiple approaches towards transaminitis management in patients with RA receiving Methotrexate (MTX).

Data were obtained from the previous work (2006) on 295 patients with RA undergoing MTX treatment. Those who developed transaminitis at least one time were selected for this study. Then, the physicians' decisions regarding discontinuing, decreasing, or prescribing a fixed dose of MTX along with the effect of each decision on the next liver enzyme were evaluated.

Strategies of decreasing dose or discontinuing MTX were adopted in 31.4% of patients and prescribing fixed dose was done in 53.9% of patients, leading to 93% and 65% next enzyme normalization, respectively. Thirty-four patients had definite MTX induced transaminitis and 55.9% of the physicians decided to decrease MTX dose for them, causing normalization of the next enzyme in 83% of these patients. In contrast, continuing MTX, even with the same dose, in definite MTX induced transaminitis cases led to consecutive enzyme elevations in 88.9% of these patients (p=0.001).

Normalization of liver enzymes was observed after decreasing dose or discontinuing MTX, suggesting this policy as the best practice for the management of MTX induced transaminitis. However, the trend to improvement, despite the type of physicians' decision, was observed. This trend was not found in definite MTX induced transaminitis, revealing the prominence of the physician's policy in this situation.