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Is there still a place for methotrexate in severe psoriatic arthritis?

Renaud Felten1, Grégoire Lambert De Cursay2, Eric Lespessailles3

  • 1Department of Rheumatology and Centre de Référence National des Maladies Auto-Immunes Systémiques Rares CIC-P Hautepierre, INSERM 1434, University Hospital of Strasbourg, Strasbourg, France.

Therapeutic Advances in Musculoskeletal Disease
|April 25, 2022
PubMed

Insights

Methotrexate (MTX) is not recommended as a first-line treatment for severe psoriatic arthritis (PsA). Evidence suggests limited benefits over placebo, and targeted therapies are preferred for early, severe cases.

Area of Science:

  • Rheumatology
  • Immunology
  • Pharmacology

Background:

  • Psoriatic arthritis (PsA) management historically mirrored rheumatoid arthritis (RA) treatment paradigms.
  • Methotrexate (MTX) was widely adopted due to its efficacy in RA during the 1990s.

Purpose of the Study:

  • To critically evaluate the current evidence supporting methotrexate (MTX) as a first-line therapy for psoriatic arthritis (PsA).
  • To clarify the role of MTX in PsA management, especially in severe or advanced disease stages.

Main Methods:

  • Narrative review of collective evidence-based medicine.
  • Analysis of systematic reviews, including a recent Cochrane review on MTX efficacy in PsA.

Main Results:

  • Evidence does not support MTX as first-line therapy in severe PsA; low-dose MTX showed minimal efficacy over placebo.
  • The structural effects of MTX in PsA remain unclear.
  • Subjective side effects like fatigue can lead to patient-initiated MTX withdrawal.
  • MTX combined with targeted therapies offers limited added benefit and may not improve efficacy.

Conclusions:

  • Severe PsA patients with axial disease, radiographic lesions, or extensive joint/skin involvement require early targeted therapy, not MTX.
  • MTX's role in PsA is limited, and it may primarily support the maintenance of TNF inhibitors without enhancing efficacy.
  • Current practices in PsA management should evolve beyond the historical reliance on MTX.
Keywords:
TNFαbDMARDsbiologic therapymethotrexatepsoriatic arthritistsDMARDS

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