Methotrexate Practices for Psoriasis Vary Widely Among Dermatologists
Craig A. Elmets, MD
An international survey uncovers differences in methotrexate treatment of psoriasis among dermatologists and from current recommendations.
Methotrexate has been a mainstay of psoriasis treatment for over 50 years. Because it received regulatory approval before carefully conducted clinical trials were required, evidence-based protocols for psoriasis treatment are rare. Guidelines on methotrexate treatment of psoriasis have been published (J Am Acad Dermatol 2009; 60:824 and 61:451; J Eur Acad Dermatol Venereol 2009; 23:1). These investigators surveyed dermatologists regarding methotrexate therapy for psoriasis in clinical practice; 481 dermatologists from 63 countries, including 10 from the U.S., responded.
The most common starting dose was 7.5 mg per week; more than two thirds recommended an initial dose of 10 mg or less. Although the mean maximum recommended dose was 22.1 ± 5.3 mg/week, about 20% supported a maximum dose <15 mg/week. Nearly 40% did not consider total cumulative dose important. The 60% who did were equally divided in choosing maximum cumulative doses of 1.5 grams, 2.0 grams, and 3.0 grams; about 10% supported higher total cumulative doses. Over 80% of respondents prescribed folic acid for methotrexate recipients (range, 5 mg/week to 30 mg/week).
Slightly more than 20% gave test doses at methotrexate initiation. Virtually all ordered complete blood counts and hepatic function tests; approximately two thirds evaluated prospective recipients for hepatitis B and C. Chest X-rays, skin tests, or interferon release tests were used by 70% to detect tuberculosis. Some tested for renal function, antinuclear antibodies, and HIV serology. Long-term monitoring for liver toxicity was performed using procollagen 3 amino terminal peptide and elastography (mostly in Europe) and liver biopsy (in the U.S. and Near East).
Citation(s):
Gyulai R et al. Current practice of methotrexate use for psoriasis: Results of a worldwide survey among dermatologists. J Eur Acad Dermatol Venereol 2014 Apr 15; [e-pub ahead of print].
