In pediatric inflammatory bowel disease (IBD), there has been an uptick in the usage of methotrexate (MTX) over the last 10 years. This coincides with malignancy concerns, particularly hepatosplenic T-cell lymphoma, with thiopurine use. Recently, a retrospective study examines the use of MTX in a cohort of 290 patients from 19 centers. 172 received monotherapy with MTX for >3 months and had at least one year of followup.
- 81 of these 172 used MTX as their first immunomodulator (IMM) (monotherapy) and this had become more prevalent towards the end of the study period (60% in 2010). Among these 81, 27% achieved a sustained clinical remission –based on physician global assessment.
- 35% who used MTX as their second IMM achieved a sustained clinical remission.
- Among MTX users, 15% had increased ALT (>60 IU/L) and 12% had white blood cells <4000 cells/mL.
- There was wide variation in usage of MTX therapy among different pediatric centers.
- According to Figure 2, there was little difference in the usage of MTX between males and females. Given the well-recognized teratogenicity with MTX, it is interesting that the authors did not elaborate on this finding.
One limitation of this study was the absence of data regarding route of MTX administration. Oral bioavailability is likely a little lower than with parental dosing. Another limitation was reliance on physician global assessment without correlating a marker for mucosal healing.
Take-home message: Methotrexate is being used more frequently as a first-line IMM. As there are no head-to-head comparison studies with thiopurines, one can only speculate whether its efficacy and safety are good enough to chosen as the first immunomodulator.
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