The value of a baseline liver biopsy prior to methotrexate treatment

Two patients with severe disabling psoriasis were treated with methotrexate (MTX). As a short course of treatment was envisaged, a pretreatment liver biopsy was not performed. Although both patients developed similarly abnormal levels of hepatic enzymes after low cumulative doses of MTX (440 and 450 mg), subsequent liver biopsies revealed contrasting findings. In one patient the histological features were normal. However, in the second, there was hepatic fibrosis, and the absence of a pretreatment biopsy led to problems with interpretation of these histological findings. As a liver biopsy is by far the most reliable method of detecting liver disease, we suggest that it is still of value to include a baseline liver biopsy in the pretreatment assessment of patients even when only a short course of MTX is planned.