Efficacy Of Methotrexate Research Articles

Oncogenic β-catenin-driven liver cancer is susceptible to methotrexate-mediated disruption of nucleotide synthesis.

Liver cancer is largely resistant to chemotherapy. This study aimed to identify the effective chemotherapeutics for β-catenin-activated liver cancer which is caused by gain-of-function mutation of catenin beta 1 ( CTNNB1 ), the most frequently altered proto-oncogene in hepatic neoplasms. Constitutive β-catenin-activated mouse embryonic fibroblasts (MEFs) were established by deleting exon 3 ( β-catenin Δ(ex3)/+ ), the most common mutation site in CTNNB1 gene. A screening of 12 widely used chemotherapy drugs was conducted for the ones that selectively inhibited β-catenin Δ(ex3)/+ but not for wild-type MEFs. Untargeted metabolomics was carried out to examine the alterations of metabolites in nucleotide synthesis. The efficacy and selectivity of methotrexate (MTX) on β-catenin-activated human liver cancer cells were determined in vitro . Immuno-deficient nude mice subcutaneously inoculated with β-catenin wild-type or mutant liver cancer cells and hepatitis B virus ( HBV ); β-catenin lox(ex3)/+ mice were used, respectively, to evaluate the efficacy of MTX in the treatment of β-catenin mutant liver cancer. MTX was identified and validated as a preferential agent against the proliferation and tumor formation of β-catenin-activated cells. Boosted nucleotide synthesis was the major metabolic aberration in β-catenin-active cells, and this alteration was also the target of MTX. Moreover, MTX abrogated hepatocarcinogenesis of HBV ; β-catenin lox(ex3)/+ mice, which stimulated concurrent Ctnnb1- activated mutation and HBV infection in liver cancer. MTX is a promising chemotherapeutic agent for β-catenin hyperactive liver cancer. Since repurposing MTX has the advantages of lower risk, shorter timelines, and less investment in drug discovery and development, a clinical trial is warranted to test its efficacy in the treatment of β-catenin mutant liver cancer.

Intralesional Methotrexate for Treatment of Alopecia Areata: Clinical Evaluation and Effect on Lesional TNF Alpha

Abstract Background Alopecia areata (AA) is an organ-specific autoimmune disease characterized by T-cell infiltrates and cytokine production including tumor necrosis factor alpha (TNF-α). Methotrexate causes T cell apoptosis and adenosine release that involves inhibition of TNF-α that could be the mechanism of action in AA. Aim of the Work To assess the efficacy of intralesional methotrexate in the treatment of alopecia areata and study its effect on TNF alpha tissue levels compared to before. Patients and Methods 30 patients were injected by intralesional methotrexate every two weeks for 3 months and a scalp biopsy was taken before and after treatment to measure lesional TNF-α. Results There was significant hair regrowth after methotrexate treatment with significant decrease in lesional TNF-α. Conclusion Intralesional methotrexate is an effective treatment for alopecia areata with mechanism of action involving decrease of TNF-α.

Evaluation of the influence of polymorphisms of the transporter genes (<i>RFC1</i>, <i>MDR1</i>) and <i>GGH</i> on the efficacy of methotrexate in rheumatoid arthritis

The efficacy of methotrexate (MT) in patients with rheumatoid arthritis (RA) may be determined by genetic factors.Objective: to evaluate the isolated and combined effects of single nucleotide polymorphisms (SNPs) of membrane transporter proteins (RFC1 80G>A and MDR1 3435C>T) and the GGH -401C>T gamma-glutamyl hydrolase enzyme genes on the efficacy of MT in patients with RA.Material and methods. The study group consisted of 85 patients with a confirmed diagnosis of RA, who received therapy with MT starting at 10 mg/week and increasing in dose to a maximum of 25 mg/week. Efficacy was assessed after six months of treatment using the dynamics of the DAS28 index, identifying patients who responded and those who did not respond to MT therapy.Genotyping of RFC1, MDR1 and GGH gene polymorphisms was performed by real-time polymerase chain reaction. Three different approaches were used to analyze the results: 1) analysis for each of the genes; 2) logistic regression; and 3) multifactor dimensionality reduction (MDR).Results and discussion. Single gene analysis was used to determine the most likely predictors of non-response to therapy: 1) for GGH-401C>T, TT genotype (odds ratio, OR 5.09; 95% confidence interval, C11.11—23.3); 2) forMDR13435C>T, the TT genotype (OR 2.38; 95% CI0.89-6.37); 3) for RFC180G>A, not - AA genotype (OR 1.87; 95% CI 0.93-3.76).The logistic regression model showed a significant effect of homozygous genotype GGH -401TT on the efficacy of MT with low sensitivity of the method. The multifactorial dimensionality reduction results show a significant synergistic effect of the MT transport genes (MDR1, RFC1) and the GGH enzyme encoding the conversion of MT to the elimination form.Conclusion. Using various statistical methods, the following results were obtained: Single gene analysis revealed the most likely predictors of nonresponse to MT therapy: GGH -401C>T - TT genotype, MDR1 3435C>T - TT genotype, RFC1 80G>A - not-AA genotype; the method of multiple logistic regression allowed to determine the significant effect of GGH -401ТТ genotype on the effect of the drug with a low sensitivity of the method; the isolated effect of polymorphisms is probably less pronounced than their combined effect on the effectiveness of MT. SNP synergism is a major contributor to the development of treatment resistance. MDR is a promising method that can be used in the future to assess the impact of SNPs.

Treatment with Methotrexate in Infants and Toddlers with Atopic Dermatitis: A Retrospective Multi-Center Study.

Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting up to 20% of children. Methotrexate (MTX) is used off-label as a systemic treatment for AD patients unresponsive to topical therapies, but limited data exist regarding its safety and efficacy in children, especially in those < 4 years old. To further investigate MTX in younger patients, we screened the medical records of three referral centers between 2016 and 2022 and identified 28 infants and toddlers < 4 years old with AD treated with MTX. Mean age upon MTX initiation was 2.7 ± 1.2 years and mean investigator global assessment (IGA) score was 3.78 ± 0.4. Median duration of MTX treatment was five months. Following 12 and 24 weeks of MTX treatment, the response rate was 50% and IGA 0/1 was achieved in 14.2% and 21.4% of patients, respectively. Most treatment cessations were attributed to a lack of efficacy or parental concern. Although adverse events were reported in 57.1% of patients, MTX was discontinued due to such adverse events only in two patients (7.1%). Taken together, MTX demonstrated a high safety profile in AD patients <4 years old. MTX efficacy was moderate and presumably underestimated by parents who opted for premature treatment cessation due to concerns associated with an immunomodulatory drug.

First-line induction chemotherapy with high-dose methotrexate versus teniposide in patients with newly diagnosed primary central nervous system lymphoma: a retrospective, multicenter cohort study

BackgroundThis study aimed to compare the efficacy and safety of high-dose methotrexate (HD-MTX) versus teniposide (TEN) in patients with newly diagnosed immunocompetent primary central nervous system lymphomas (PCNSLs).MethodsThe study included immunocompetent, adult patients with newly diagnosed PCNSL at 22 centers in China from 2007 to 2016. The patients received HD-MTX or TEN as first-line induction therapy. The objective response rate, progression-free survival, and overall survival were analyzed for each patient cohort.ResultsA total of 96 patients were eligible: 62 received HD-MTX, while 34 received teniposide. The overall response rate was 73.2% and 72.7% in the MTX and the TEN cohorts, respectively (P = 0.627). The median progression-free survival was 28.4 months [95% confidence interval (CI): 13.7–51.2] in the MTX cohort and 24.3 months (95% CI: 16.6–32.1) in the TEN cohort (P = 0.75). The median overall survival was 31 months (95% CI: 26.8–35.2) in the MTX cohort and 32 months (95% CI: 27.6–36.4) in the TEN cohort (P = 0.77). The incidence of any grade of coagulopathy/deep-vein thrombosis and gastrointestinal disorders was significantly higher in the MTX cohort than in the TEN cohort; no significant difference was found in the incidence of other adverse events between the two cohorts.ConclusionsThis was the first multicenter study using TEN as the main agent compared with HD-MTX in newly diagnosed primary CNS lymphoma. The TEN-based regimen was non-inferior to the HD-MTX-based regimen with similar overall responses.Classification of evidenceThis study provided Class III evidence that the teniposide-based regimen was non-inferior to high-dose methotrexate − based regimen with similar overall responses and long-time survival in immunocompetent patients with PCNSL.

A Combination Therapy of Methotrexate and Xianling Gubao Capsule for Female Patients with Moderate to Severe Active Rheumatoid Arthritis and its Impact on Ovarian Function

Rheumatoid arthritis is a common immune disease with early symptoms of joint swelling, morning stiffness, pain, and swelling. It could develop into a joint deformity as the disease progresses, resulting in the loss of normal joint function and seriously affecting the patient’s quality of life. Methotrexate is the “anchor drug” for rheumatoid arthritis treatment, which has an immunosuppressive effect and could effectively prevent the abnormal activation of B cells in vivo, inhibit the abnormal generation of cytokines, and relieve related symptoms. However, in some cases, methotrexate alone is not ideal and often needs to be combined with other drugs like xianlinggubao capsules. This study has provided an experimental basis for the combined efficacy of methotrexate and xianlinggubao capsules for female patients with moderate to severe rheumatoid arthritis and their impact on ovarian function.

Efficacy of intrathecal methotrexate in children with high-risk medulloblastoma over three years: a retrospective study from a single center

PurposeChemotherapy is commonly used for treatment in children over three years old with high-risk medulloblastoma(MB). However, little is currently known about the therapeutic benefits and side effects of intrathecal methotrexate(MTX), warranting further research.MethodsIn this retrospective study, patients who received intrathecal MTX during chemotherapy were included in the MTX group (n = 32), and patients that only underwent cerebrospinal fluid (CSF) cytology analysis were assigned to the control group (n = 14).ResultsIn the MTX group, 27(84.38%) patients had metastatic disease, 3(9.38%) had diffuse anaplasia, and 3(9.38%) had residual disease greater than 1.5 cm2. Molecular subgroup classification was available for 28(87.5%) patients. In the control group, 8(57.14%) patients had metastatic disease, 3(27.27%) had diffuse anaplasia, and 6(42.86%) had residual disease greater than 1.5 cm2. Molecular subgroup classification was available for 6(42.86%) patients. The 5-year progression-free survival was 70.99% and the 5-year overall survival was 72.99% for the MTX group, and the corresponding values were 41.67% and 50% for the control group, respectively. 6 (18.75%) patients in the MTX group with group 4 disease developed MTX-related acute leukoencephalopathy and one of them died.ConclusionsOur findings support the addition of intrathecal MTX during chemotherapy as the optimal management for children with group 3 and SHH high-risk MB. However, it is not recommended for group 4 MB patients, especially in resource-limited regions.Trial registration number: Retrospective registered No.(2020 − 117).

Prospective Analysis of Immunosuppressive Therapy in Cardiac Sarcoidosis With Fluorodeoxyglucose Myocardial Accumulation: The PRESTIGE Study

BackgroundFluorodeoxyglucose positron emission tomography (18F-FDG-PET) can noninvasively assess active inflammatory myocardium in patients with cardiac sarcoidosis (CS). Prednisolone (PSL) is the initial drug of choice for active CS; however, its efficacy has not been prospectively evaluated. Moreover, there are no alternative systematic treatment strategies. ObjectivesThe goal of this study was to evaluate the efficacy of methotrexate (MTX) in patients refractory to PSL assessed by using cardiac metabolic activity (CMA) in 18F-FDG-PET. MethodsA total of 59 patients with active CS were prospectively enrolled. CMA (standardized uptake value × accumulation area) was used as an indicator of active inflammation, and a 6-month regimen of PSL therapy was introduced, followed by a second FDG scan. Poor responders to PSL therapy (CMA reduction rate <70%) and patients with recurrent CS (CMA reduction rate ≥70% after initial PSL therapy but CMA recurred after an additional 6 months of therapy) were randomly assigned to the MTX or repeat PSL (re-PSL) therapy groups for another 6 months. ResultsFifty-six patients completed the initial 6-month PSL therapy regimen. Median CMA reduced from 203.3 to 1.0 (P < 0.001), and 47 patients were allocated to the response group, 9 to the poor response group, and 2 to the recurrent group. Accordingly, 11 patients were randomly assigned to the MTX (n = 5) or re-PSL (n = 6) groups. After 6 months, neither group showed a significant reduction in CMA values. MTX was comparable to re-PSL in reducing CMA. ConclusionsThe 6-month regimen of PSL was a potent therapeutic tool for active CS. When MTX was added to low-dose PSL in patients refractory to the initial PSL therapy, there was no significant difference compared with re-PSL. Further studies are needed to evaluate the therapeutic potential of MTX for active CS, including how MTX works when it is administered in higher doses or for longer periods.

A Comparative Study of the Efficacy of Methotrexate versus Methotrexate with Apremilast in Moderate to Severe Chronic Plaque Psoriasis.

Psoriasis is an inflammatory systemic disease with a chronic relapsing course. Methotrexate, a dihydrofolate reductase inhibitor, and Apremilast, an oral phosphodiesterase type 4 inhibitor, are currently the mainstay drugs in the treatment of psoriasis. To compare the efficacy of Methotrexate with a combination of Methotrexate and Apremilast in treating chronic plaque psoriasis. The present study was a prospective comparative study conducted among 40 patients, aged above 18 years, with clinically diagnosed psoriasis attending Dermatology OPD of a tertiary care hospital in North India. The study utilised a pre-structured proforma to record a detailed demographic profile and clinical examination related to chronic plaque psoriasis. The patients were divided into two groups of 20 each. Group A was treated with oral Methotrexate, while Group B was treated with oral Apremilast and Methotrexate, and they were evaluated every 4 weeks for 12 weeks. Necessary investigations were done wherever indicated. The male-to-female ratio was 1.35, and the majority (55.0%) of patients belonged to the age group of 31-50 years. 27.5% of patients had comorbidities like diabetes, hypertension, etc., The mean PASI score of group A at the first, second and third follow-ups was higher than that of group B. The reduction in mean PASI score was statistically significant in group B at successive follow-ups, with a percentage improvement of 89.4% at the end of 12 weeks. When comparing monotherapy with methotrexate and multidrug therapy with Methotrexate and Apremilast, multidrug therapy had better efficacy.

A Randomized, Double-Blind, Placebo-Controlled Multicenter Efficacy and Safety Study of Methotrexate to Increase Response Rates in Patients With Uncontrolled Gout Receiving Pegloticase: 12-Month Findings.

To assess 12-month safety and efficacy of pegloticase + methotrexate (MTX) versus pegloticase + placebo (PBO) cotherapy in a PBO-controlled, double-blind trial (A randomized, double-blind, placebo-controlled, multicenter, efficacy and safety study of methotrexate to increase response rates in patients with uncontrolled gout receiving pegloticase [MIRRORRCT]). Patients with uncontrolled gout (serum urate level [SU] ≥7 mg/dl, oral urate-lowering therapy failure or intolerance, and presence of one or more gout symptoms [one or more tophi, two or more flares in 12 months, gouty arthropathy]) were randomized 2:1 to receive pegloticase (8-mg infusion every 2 weeks) with blinded MTX (oral 15 mg/week) or PBO for 52 weeks. Efficacy end points included proportion of responders (SU level <6 mg/dl for ≥80% of examined month) in the intent-to-treat population (ITT) (all randomized patients) during month 6 (primary end point), month 9, and month 12; proportion with resolution of one or more tophi (ITT); mean SU reduction (ITT); and time to SU-monitoring pegloticase discontinuation. Safety was evaluated via adverse event reporting and laboratory values. Month 12 response rate was significantly higher in patients cotreated with MTX (60.0% [60 of 100] vs. 30.8% [16 of 52]; difference: 29.1% [95% confidence interval (CI): 13.2%-44.9%], P = 0.0003), with fewer SU discontinuations (22.9% [22 of 96] vs. 63.3% [31 of 49]). Complete resolution of one or more tophi occurred in 53.8% (28 of 52) versus 31.0% (9 of 29) of MTX versus PBO patients at week 52 (difference: 22.8% [95% CI: 1.2%-44.4%], P = 0.048), more than at week 24 (34.6% [18 of 52] vs. 13.8% [4 of 29]). Consistent with observations through month 6, pharmacokinetic and immunogenicity findings showed increased exposure and lower immunogenicity of pegloticase when administered with MTX, with an otherwise similar safety profile. No infusion reactions occurred after 24 weeks. Twelve-month MIRROR RCT data further support MTX cotherapy with pegloticase. Tophi resolution continued to increase through week 52, suggesting continued therapeutic benefit beyond month 6 for a favorable treatment effect.

EFFICACY OF METHOTREXATE ALONE OR WITH LOW-DOSE PREDNISONE IN ALOPECIA AREATA TOTALIS

This study aimed to evaluate the efficacy of methotrexate alone or in combination with low-dose prednisone in treating alopecia areata totalis. A randomized controlled trial was conducted among 100 patients diagnosed with alopecia areata totalis. Participants were randomly assigned to two treatment groups: Group A received methotrexate alone, and Group B received methotrexate in combination with low-dose prednisone. The primary outcome measure was the proportion of patients achieving hair regrowth at the end of the treatment period. Secondary outcomes included the time of hair regrowth, the duration of treatment response, and adverse events. Of the 100 patients, 50 were assigned to Group A and 50 to Group B. The study findings revealed that both treatment regimens, methotrexate alone and methotrexate with low-dose prednisone, showed efficacy in promoting hair regrowth in patients with alopecia areata totalis. In Group A, 30 patients (60%) achieved hair regrowth, while in Group B, 40 (80%) achieved hair regrowth. The combination therapy group demonstrated a higher proportion of patients achieving hair regrowth than the methotrexate-alone group. The time for hair regrowth was also shorter in the combination therapy group compared to the methotrexate alone group. Adverse events were minimal and comparable between the two groups. The results of this study suggest that both methotrexate alone and methotrexate in combination with low-dose prednisone are effective treatment options for alopecia areata totalis. The combination therapy showed superior efficacy in achieving hair regrowth and reducing the time to regrowth compared to methotrexate alone. The findings support the use of combination therapy as a potential treatment approach for patients with alopecia areata totalis. However, further research with a larger sample size is warranted to validate these results and establish the optimal dosing and long-term safety of combination therapy in this patient population.

Pharmacogenetic Sex-Specific Effects of Methotrexate Response in Patients with Rheumatoid Arthritis.

Methotrexate (MTX) is a commonly used drug for the treatment of rheumatoid arthritis (RA), but its effectiveness can vary greatly among patients. Pharmacogenetics, the study of how genetic variations can affect drug response, has the potential to improve the personalized treatment of RA by identifying genetic markers that can predict a patient's response to MTX. However, the field of MTX pharmacogenetics is still in its early stages and there is a lack of consistency among studies. This study aimed to identify genetic markers associated with MTX efficacy and toxicity in a large sample of RA patients, and to investigate the role of clinical covariates and sex-specific effects. Our results have identified an association of ITPA rs1127354 and ABCB1 rs1045642 with response to MTX, polymorphisms of FPGS rs1544105, GGH rs1800909, and MTHFR genes with disease remission, GGH rs1800909 and MTHFR rs1801131 polymorphisms with all adverse events, and ADA rs244076 and MTHFR rs1801131 and rs1801133, However, clinical covariates were more important factors to consider when building predictive models. These findings highlight the potential of pharmacogenetics to improve personalized treatment of RA, but also emphasize the need for further research to fully understand the complex mechanisms involved.

Whey-based diet containing medium chain triglycerides modulates the gut microbiota and protects the intestinal mucosa from chemotherapy while maintaining therapy efficacy

Cytotoxicity (i.e. cell death) is the core mechanism by which chemotherapy induces its anti-cancer effects. Unfortunately, this same mechanism underpins the collateral damage it causes to healthy tissues. The gastrointestinal tract is highly susceptible to chemotherapy’s cytotoxicity, resulting in ulcerative lesions (termed gastrointestinal mucositis, GI-M) that impair the functional capacity of the gut leading to diarrhea, anorexia, malnutrition and weight loss, which negatively impact physical/psychological wellbeing and treatment adherence. Preventing these side effects has proven challenging given the overlapping mechanisms that dictate chemotherapy efficacy and toxicity. Here, we report on a novel dietary intervention that, due to its localized gastrointestinal effects, is able to protect the intestinal mucosal from unwanted toxicity without impairing the anti-tumor effects of chemotherapy. The test diet (containing extensively hydrolyzed whey protein and medium chain triglycerides (MCTs)), was investigated in both tumor-naïve and tumor-bearing models to evaluate its effect on GI-M and chemo-efficacy, respectively. In both models, methotrexate was used as the representative chemotherapeutic agent and the diet was provided ad libitum for 14 days prior to treatment. GI-M was measured using the validated biomarker plasma citrulline, and chemo-efficacy defined by tumor burden (cm3/g body weight). The test diet significantly attenuated GI-M (P = 0.03), with associated reductions in diarrhea (P < 0.0001), weight loss (P < 0.05), daily activity (P < 0.02) and maintenance of body composition (P < 0.02). Moreover, the test diet showed significant impact on gut microbiota by increasing diversity and resilience, whilst also altering microbial composition and function (indicated by cecal short and brained chain fatty acids). The test diet did not impair the efficacy of methotrexate against mammary adenocarcinoma (tumor) cells. In line with the first model, the test diet minimized intestinal injury (P = 0.001) and diarrhea (P < 0.0001). These data support translational initiatives to determine the clinical feasibility, utility and efficacy of this diet to improve chemotherapy treatment outcomes.

Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus.

After decades of use, methotrexate displays an established safety and efficacy profile in both in-hospital and outpatient settings. Despite its widespread use, there is surprisingly little clinical evidence to guide daily practice with methotrexate in dermatology. To provide guidance for clinicians in daily practice for areas in which there is limited guidance. A Delphi consensus exercise on 23 statements was carried out on the use of methotrexate in dermatological routine settings. Consensus was reached on statements that cover six main areas: (1) pre-screening exams and monitoring of therapy; (2) dosing and administration in patients naïve to methotrexate; (3) optimal strategy for patients in remission; (4) use of folic acid; (5) safety; and (6) predictors of toxicity and efficacy. Specific recommendations are provided for all 23 statements. In order to optimize methotrexate efficacy, it is essential to optimize treatment using appropriate dosages, carrying out a rapid drug-based step-up on a treat-to-target strategy and preferably using the subcutaneous formulation. To manage safety aspects appropriately, it is essential to evaluate patients' risk factors and carry out proper monitoring during the course of treatment.

Comparison of efficacy of Methoterexate versus Acitretin in the treatment of chronic plaque psoriasis

Objective: To compare the efficacy of methotrexate versus acitretin in the treatment of chronic plaque psoriasis Method: Randomized controlled Trial conducted in Dermatology Department, Services Hospital Lahore, on 60 patients after informed consent, divided into two groups. Group A given methotrexate 0.30.5mg/kg orally and group B given acitretin 0.4mg/kg orally. Efficacy was ascertained by reduction in PASI score, calculated at baseline and at the 12 weeks. Results:Patients of Group A achieved a reduction in PASI score from baseline 13.13±2.047 to 6.20±2.024 (efficacy 76.7%) while in Group B, PASI score dropped from 13.53±2.047 to 7.00±1.857 (efficacy 56.7%). Adverse effects for both groups were minimal and as expected. Conclusion: Both methotrexate and acitretin are highly effective drugs in treating chronic plaque psoriasis. However, methotrexate shows greater efficacy and faster reduction in PASI as compared to acitretin.

Intralesional methotrexate in the treatment of localized vitiligo: A pilot study.

Vitiligo is an immune-mediated skin disorder that targets epidermal melanocytes leading to the appearance of depigmented skin patches. Different treatment modalities have been reported with varied efficacy. We tried to evaluate the safety and efficacy of intralesional methotrexate in treating localized areas of vitiligo. Thirty participants with localized patches of vitiligo were recruited. They were treated with intralesional injections of methotrexate every 2 weeks for a maximum of six sessions. At the end of the study, the degree of repigmentation was categorized into: excellent improvement (>75% repigmentation), good improvement (50%-75% repigmentation), fair improvement (25%-50% repigmentation) and poor improvement (<25% repigmentation). We included 7 males (23.3%) and 23 females (76.7%). Their mean age was 33.6 ± 8.6 years. The duration of the disease ranged from 1 to 22 years. Four patients had a family history of vitiligo. At the end of the study, there was a highly statistically significant improvement (p < 0.001) after treatment regarding repigmentation. This study showed that intralesional methotrexate is a safe and effective treatment option for patients with localized vitiligo lesions. Further studies on a larger scale are needed to evaluate the long-term effects of treatment and detect the ideal dose to be injected.

P114 Exploring micro-RNA content of circulating extracellular vesicles as biomarkers in early rheumatoid arthritis

Abstract Background/Aims Early diagnosis and prompt and effective intervention for people with immune-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis (RA) improves outcomes. Non-invasive biomarkers that reflect unique aspects of underlying biology could facilitate this. Extracellular vesicles (EVs) released by many cell types are abundantly present in body fluids where they contribute to intercellular signalling by transferring cargo including microRNAs (miRs) - themselves implicated in disease pathogenesis. We investigated whether serum EV miR expression (i) discriminates patients with newly presenting, untreated RA from those with an alternative IMID or none, (ii) predicts therapeutic response to first-line methotrexate (MTX) treatment amongst RA patients, or, in the same individuals (iii) exhibit dynamically altered expression in MTX-responders versus non-responders during treatment. Methods Using a validated protocol, serum EVs were isolated from 43 early RA patients. Identically isolated EV were available from sera of 23 newly presenting, untreated polymyalgia rheumatica (PMR, “IMID control”) patients and 12 “non-inflammatory control” patients (NICs) in whom significant inflammatory disease had been excluded. miRs were isolated and subject to NanoString sequencing (798 miRs). Following quality control, DESeq2 was first used to identify miRs uniquely deregulated in RA EVs at baseline. Within the early RA cohort, a baseline comparison between individuals who subsequently achieved clinical remission after 6 months treatment with MTX (DAS28-CRP&amp;lt;2.4 without having required systemic steroids in preceding 2 months) and those that did not, was also undertaken by partial least squared-discriminant analysis (PLS-DA) with 5-fold cross validation. Linear modelling was used to assess differences in dynamic EV miR expression between responders and non-responders. Multiple test correction was applied (false discovery rate; FDR). Results A signature of 28 miRs uniquely differentially expressed between early RA patients and NICs (i.e. not also between PMR and NICs) was identified, which was robust to MTC after correction for age and sex. Amongst those upregulated in RA were miR-337-3p, whose predicted target proteins include Jak2 and STAT3, and miR-144-3p, recently shown to mediate the expression of pro-inflammatory cytokines and chemokines by macrophages. Whilst EV miRs differentially expressed at baseline between RA patients who subsequently achieved early MTX-induced remission and those who did not were not robust to MTC, PLS-DA indicated their predictive potential. Finally, several miRs whose change in expression over the course of treatment differed significantly between responders and non-responders; namely miR-548ar-3p, miR-212-3p, miR-188-5p, miR-410-3p, and miR-338-5p amongst others, may offer insight into the mechanism of MTX’s therapeutic action. Conclusion Serum EV miRs are a possible source of clinically valuable biomarkers that may shed light on pathophysiology and/or mechanisms of MTX efficacy. Our findings highlight their potential as diagnostic and prognostic tools in early RA. Larger studies and validation in independent cohorts are warranted to pursue this potential, alongside mechanistic evaluation. Disclosure D. Maunder: None. P.M. Brown: None. B. Barron-Millar: None. D. Lendrem: None. N. Naamane: None. J. Macdonald: None. X. Wang: None. A.E. Anderson: None. A.W. Morgan: None. S.L. Mackie: Consultancies; Roche/Chugai, Sanofi, AbbVie and AstraZeneca. Honoraria; Pfizer, Vifor and UCB. Grants/research support; Vifor. R. Crossland: None. A.G. Pratt: Consultancies; Inflection Biosciences.

Methotrexate as a corticosteroid-sparing agent in leprosy reactions: A French multicenter retrospective study.

Leprosy reactions (LRs) are inflammatory responses observed in 30%-50% of people with leprosy. First-line treatment is glucocorticoids (GCs), often administered at high doses with prolonged courses, resulting in high morbi-mortality. Methotrexate (MTX) is an immunomodulating agent used to treat inflammatory diseases and has an excellent safety profile and worldwide availability. In this study, we describe the efficacy, GCs-sparing effect and safety of MTX in LRs. We conducted a retrospective multicentric study in France consisting of leprosy patients receiving MTX for a reversal reaction (RR) and/or erythema nodosum leprosum (ENL) since 2016. The primary endpoint was the rate of good response (GR) defined as the complete disappearance of inflammatory cutaneous or neurological symptoms without recurrence during MTX treatment. The secondary endpoint was the GCs-sparing effect, safety and clinical relapse after MTX discontinuation. Our study included 13 patients with LRs (8 men, 5 women): 6 had ENL and 7 had RR. All patients had had at least one previous course of GCs and 2 previous treatment lines before starting MTX. Overall, 8/13 (61.5%) patients had GR, allowing for GCs-sparing and even GCs withdrawal in 6/11 (54.5%). No severe adverse effects were observed. Relapse after MTX discontinuation was substantial (42%): the median relapse time was 5.5 months (range 3-14) after stopping treatment. MTX seems to be an effective alternative treatment in LRs, allowing for GCs-sparing with a good safety profile. Furthermore, early introduction during LRs may lead to a better therapeutic response. However, its efficacy seems to suggest prolonged therapy to prevent recurrence.

Efficacy and Safety of Methotrexate Plus Leflunomide in Patients of Rheumatoid Arthritis not Responding to Methotrexate Alone

Introduction: Rheumatoid Arthritis (RA) is a chronic inflammatory disease affecting approximately 0.24% of the global population and can lead to joint destruction, functional decline, disability, and decreased quality of life. According to ACR and EULAR guidelines, patients with RA should initiate treatment with conventional synthetic Disease-Modifying Antirheumatic Drugs (csDMARDs), such as Methotrexate (MTX). In patients with an inadequate response to csDMARDs, it is recommended to add a targeted synthetic DMARD, such leflunomide or a biologic DMARD (bDMARD), such as tumor necrosis factor inhibitor (TNFi). Objectives: To study the efficacy and safety of methotrexate and leflunomide in patients of Rheumatoid arthritis not responding to methotrexate alone. Materials and Methods: It was a single centre, observational study in 50 patients of Rheumatoid Arthritis taking methotrexate plus leflunomide after inadequate response to methotrexate monotherapy (15mg/week) for 12 weeks. Patients were included in the study after meeting inclusion and exclusion criteria. Patients were taking leflunomide in a dose of 10 mg/day and methotrexate in a dose of 15 mg/week with Folic acid 5 mg/week. Efficacy outcomes; ACR 20/50/70 and DAS-28 CRP based remission/low disease activity were assessed at 12 weeks and 24 weeks. Statistical analysis was done using Jamovi (V2.3.18) software. Results: Improvement from baseline to weeks 12 and 24 was observed for all efficacy outcomes (including ACR 20/50 and DAS-28 CRP based low disease activity/remission) in patients taking methotrexate plus leflunomide. At 24 week 64% achieved ACR-20, 44% patients achieved ACR-50, 24% patients achieved Low Disease activity (LDA) and 6% patients achieved remission. The most common adverse effect was nausea and vomiting at 24 weeks. No deaths were reported. Conclusion: In our study methotrexate and leflunomide conferred improvement in disease activity measures and functional outcomes after 24 weeks of treatment.

Methotrexate in generalized myasthenia gravis: a systematic review.

Current myasthenia gravis guidelines recommend the use of azathioprine as first-line steroid sparing agent. However, due to its high cost, compliance to azathioprine is low in developing countries. To determine the efficacy and safety of the cheaper methotrexate as an alternative immunosuppressant, Medline/Pubmed, Embase and Cochrane databases and references were searched for clinical trials and observational studies using the search terms: "Myasthenia OR Myasthenia Gravis OR anti AchR antibody positive Myasthenia Gravis OR anti-MuSK antibody Myasthenia Gravis OR MG" AND "Methotrexate". Of 78 possible articles, only 4 were selected using the following eligibility criteria: population: generalized MG patients; intervention: methotrexate; and outcome: effectiveness, steroid sparing efficacy and adverse effects. Two clinical trials and one observational study noted improvement in different MG outcomes in patients given methotrexate. While one randomized controlled clinical trial concluded that methotrexate has no steroid sparing benefit, a single blinded clinical trial established that methotrexate was a better steroid sparing agent than azathioprine starting at 10th month of use. Adverse effects were rare with non-specific pain and elevated transaminases as the most common complaints. Based on available evidence, MTX may be a safe and effective alternative to AZA as steroid sparing agent in developing countries.