Low-dose Methotrexate Research Articles

42810 Adverse Cutaneous Events of Low-Dose Methotrexate: A Systematic Review

42810 Adverse Cutaneous Events of Low-Dose Methotrexate: A Systematic Review

P29 The use of adjunct oral methotrexate as primary prevention for keloid scarring following syndactyly release surgery

Abstract A 12-month-old Asian female underwent syndactyly release surgery with advancement flap closure of the first web space of the right hand. The procedure was complicated by enlarging keloids over the surgical site and dactylitis, a rare complication with only a few previously reported cases [Muzaffar AR, Rafols F, Masson J et al. Keloid formation after syndactyly reconstruction: associated conditions, prevalence, and preliminary report of a treatment method. J Hand Surg Am 2004; 29: 201–8. https://doi.org/10.1016/j.jhsa.2003.10.017]. Initial treatment of the keloid scarring with intralesional triamcinolone under general anaesthetic was unsuccessful. Subsequently, we elected to surgically excise the keloids closing with a full-thickness skin graft from the groin, with adjunct oral methotrexate (0.4 mg kg–1 weekly) for 9 months post-surgery. The use of oral methotrexate for this indication is rarely reported: one series included two cases of successful keloid suppression with 4 years of follow-up [Muzaffar et al.] and another series of four patients with successful keloid suppression after surgery for syndactyly with dactylitis [Tolerton SK, Tonkin MA. Keloid formation after syndactyly release in patients with associated macrodactyly: management with methotrexate therapy. J Hand Surg Eur 2011; 36: 490–7]. Low-dose methotrexate exerts anti-inflammatory effects by stimulating adenosine A2 receptors and increasing adenosine release at sites of inflammation, such as surgical sites [Muzaffar et al.]. In our patient, methotrexate was well-tolerated, keloid recurrence and dactylitis were avoided, and range of movement and functioning of the digits was maintained. Keloid formation after syndactyly release poses a complex management challenge and we propose methotrexate should be considered as an adjunct to reduce recurrence risk.

Assessment of Ante- and Postnatal Development of the Offspring of Male Rats Crossed in Delayed Periods after Treatment with Methotrexate in Low Doses.

We studied ante- and postnatal development of the offspring of intact female rats crossed with males injected with low doses of methotrexate 3 and 6 months before mating. The time of crossing corresponded to the manifestation of the cytostatic effect on spermatogonial stem cells. The offspring of methotrexate-treated males was characterized by increased preimplantation losses and fetal growth restriction in the antenatal period and inhibition of physical development, delayed formation of sensory-motor reflexes, and impaired learning abilities in the postnatal period.

Pharmacokinetic–pharmacodynamic modeling of maintenance therapy for childhood acute lymphoblastic leukemia

In the treatment of childhood acute lymphoblastic leukemia (ALL), current protocols combine initial high-dose multiagent chemotherapy with prolonged oral therapy with 6-mercaptopurine (6MP) and low-dose methotrexate (MTX) maintenance therapy. Decades of research on ALL treatment have resulted in survival rates of approximately 90%. However, dose-response relationships vary widely between patients and insight into the influencing factors, that would allow for improved personalized treatment management, is insufficient. We use a detailed data set with measurements of thioguanine nucleotides and MTX in red blood cells and absolute neutrophil count (ANC) to develop pharmacokinetic models for 6MP and MTX, as well as a pharmacokinetic–pharmacodynamic (PKPD) model capable of predicting individual ANC levels and thus contributing to the development of personalized treatment strategies. Here, we show that integrating metabolite measurements in red blood cells into the full PKPD model improves results when less data is available, but that model predictions are comparable to those of a fixed pharmacokinetic model when data availability is not limited, providing further evidence of the quality of existing models. With this comprehensive model development leading to dynamics similar to simpler models, we validate the suitability of this model structure and provide a foundation for further exploration of maintenance therapy strategies through simulation and optimization.

Methotrexate Polyglutamates Exposure - Response Modeling in a Large Cohort of Rheumatoid Arthritis Patients Starting Methotrexate.

Methotrexate polyglutamates (MTX-PG) concentrations in red blood cells (RBCs) have been suggested as a biomarker of response in patients with rheumatoid arthritis (RA) receiving low-dose MTX therapy. We investigated the association and interpatient variability between RBC-MTX-PG3-5 -exposure and response in patients with RA starting MTX. Data of three prospective cohorts were available. The relationship between exposure and Disease Activity Score in 28 joints (DAS28) was analyzed using a population pharmacokinetic-pharmacodynamic model. Relevant covariates were tested using full covariate modeling and backward elimination. From 395 patients, 3,401 MTX-PG concentrations and 1,337 DAS28 measurements were available between 0 and 300 days after MTX treatment onset. The developed model adequately described the time course of MTX-PG3-5 and DAS28. The median MTX-PG3-5 level at month 1 was 30.9 nmol/L (interquartile range (IQR): 23.6-43.7; n = 41) and at month 3: 69.3 nmol/L (IQR: 17.9-41.2; n = 351). Clearance of MTX-PG3-5 from RBCs was 28% lower (95% confidence interval (CI): 23.6-32.8%) in a woman and 10% lower (95% CI: 7.7-12.4%) in a 65-year-old compared with a 35-year-old patient. MTX-PG3-5 concentrations associated with DAS28: half-maximal effective concentration (EC50 ) was 9.14 nmol/L (95% CI: 4.2 nmol/L-14.1 nmol/L). EF at 80% (EC80 ) above 47 nmol/L was regarded as the optimal response. Independent of the MTX-PG 3-5 - response association, co-administration of disease-modifying antirheumatic drugs and corticosteroids improved response (additive effect on maximum effect (Emax )), whereas smoking, high body mass index and low albumin decreased Emax . In patients with RA starting MTX, RBC-MTX-PG3-5 was associated with clinical response. A dose increase is suggested when MTX-PG3-5 at month 1 is below 9.15 nmol/L, continued with the same dose when the concentration is above 47 nmol/L, and consider other treatment options above 78 nmol/L from 3months onwards.

Zinc and L-carnitine combination with or without methotrexate prevents intestinal toxicity during arthritis treatment via Nrf2/Sirt1/Foxo3 pathways: an In vivo and molecular docking approach.

Methotrexate (MTX) is an antifolate that is inescapable and widely used to treat autoimmune diseases and is the gold standard medicine for the arthritic condition. Despite its importance, it is more prone to gastrointestinal toxicity, which is most common in arthritis patients during MTX treatment. Combination therapies are required to ensure MTX's antiarthritic activity while providing gastrointestinal protection. Zinc (Zn) and L-carnitine (Lc) are well-known potent antioxidants and anti-inflammatory supplements with promising results in pre-clinical studies. Arthritis was induced in Wistar rat's ankles with Freund's adjuvant and treated with either MTX (2.5mg/kg b.w per week for two weeks) or Zn (18mg/kg b.w. per day) Lc (200mg/kg b.w. per day) individually or in combination (MTX + Zn Lc). The antiarthritic effects were evaluated by body weight, paw volume, ankle tissue, and joint histopathology. At the same time, anti-toxicity/gastrointestinal protective activity was examined by tissue oxidative stress markers, antioxidants, mitochondrial function, inflammatory mediators, and antioxidant signaling proteins and their binding mechanism. Repercussions of MTX intoxication induced upregulation of oxidative stress markers, antioxidant depletion, ATP depletion, decreased expression of Nrf2/Sirt1/Foxo3, and the overexpression of inflammatory mediators attenuated by co-treatment with Zn Lc. Zn Lc markedly mitigated MTX-instigated intestinal injury by activating antioxidant signaling mechanisms Nrf2/Sirt1/Foxo3 signaling and tissue architectural anomalies and exhibited an enhanced antiarthritic effect. In conclusion, we report that Zn Lc and MTX combination could presumably protect the intestine from low-dose MTX which managed arthritis but induced severe intestinal damage with increased inflammation and downregulated Nrf2/Sirt1/Foxo3 pathway.

Introduction. Rheumatoid arthritis (RA) is a systemic and chronic autoimmune disease involving the joints disorder as the main manifestations. Methotrexate (MTX) is currently still the drug of choice for RA treatment due to the good clinical response. However, there was a case reported by the American Geriatric Society in 2015 regarding the presence of reversible dementia after treatment with low-dose

Introduction. Doctors have greater risk of acquiring COVID-19 due to occupational exposure. Personal protective equipment (PPE) is an essential factor in reducing COVID-19 transmission. We aimed to evaluate the behavior changes of PPE usage among doctors in Indonesia before and after getting COVID-19 infection in early pandemic. Methods. This was a descriptive online survey with cross-sectional design. This survey was conducted from October-December 2020 among Indonesian doctors who were COVID-19 survivors. Results. A total of 389 doctors who survived COVID-19 infection across Indonesia were included in the final analysis. Most participants were general practitioners and residents (69.2%) with a median age of 40 (22-28) years. After being infected, there was an improvement in the use of N95 respirator masks in isolation rooms (always: 80.9% from 70.2%; sometimes: 13.2% from 15.8%). An improvement in the use of other PPE before and after being infected with COVID-19 was also shown by the use of other PPE such as headcap (93.9% from 83.3%), face shield (90.4% from 83.3%), goggles (70.2% from 62.3%), gown (61.4% from 53.6%), hazmat suit (88.6% from 81.6%), boots (82.5% from 71.1%), and gloves (91.3% from 86.8%). Similar results were also shown in the use of PPE in other non-isolation rooms. Conclusion. After recovering from COVID-19 infection, these doctors showed an increase usage of adequate PPE both while on duty in isolation and non-isolation rooms.

Pengaruh Terapi Metotreksat pada Pasien Artritis Reumatoid terhadap Penurunan Fungsi Kognitif: Meta-Analisis Berdasarkan Telaah Sistematik

Introduction. Rheumatoid arthritis (RA) is a systemic and chronic autoimmune disease involving the joints disorder as the main manifestations. Methotrexate (MTX) is currently still the drug of choice for RA treatment due to the good clinical response. However, there was a case reported by the American Geriatric Society in 2015 regarding the presence of reversible dementia after treatment with low-dose oral methotrexate. This study aimed to identify the effect of MTX treatment on cognitive disorder in RA patients. Methods. The study protocol was registered with PROSPERO (CRD42023414937). A systematic literature search was conducted in Medline Embase database, Scopus, CENTRAL to identify cohort observational studies, case controls, and randomized control trial (RCT) studies, evaluating the effect of methotrexate therapy on cognitive function disorder in RA patients. The Newcastle-Ottawa Scale (NOS Scale) was used to analyze the quality of existing observational studies and The COCHRANE was used to analyze the RCT studies which included in the journals reviewed. Results. There were 4 observational studies that met the criteria, including 2 case control studies and 2 cohort studies. Pooling was carried out in two different types of studies. The OR was 0.81 (95%CI 0.4 – 1.68) in the case control studies group, whereas the RR was 0.88 (95% CI 0 .6 – 1.3) in the cohort studies group. The heterogeneity of each type of case-control studies and cohort studies were I2 92% (p-value277% (p-value Conclusion. Methotrexate therapy has not been proven to have an effect on cognitive disorder in RA patients either as a protective factor or as a risk factor.

The actions of methotrexate on endothelial cells are dependent on the shear stress-induced regulation of one carbon metabolism.

The disease-modifying anti-rheumatic drug methotrexate (MTX) is recognized to reduce cardiovascular risk in patients with systemic inflammatory diseases. However, the molecular basis for these cardioprotective effects remains incompletely understood. This study evaluated the actions of low-dose MTX on the vascular endothelium. Human endothelial cells (EC) were studied under in vitro conditions relevant to inflammatory arthritis. These included culture in a pro-inflammatory microenvironment and exposure to fluid shear stress (FSS) using a parallel plate model. Respectively treated cells were analyzed by RNA sequencing and quantitative real-time PCR for gene expression, by immunoblotting for protein expression, by phosphokinase activity arrays, by flow cytometry for cell cycle analyses and by mass spectrometry to assess folate metabolite levels. In static conditions, MTX was efficiently taken up by EC and caused cell cycle arrest concurrent with modulation of cell signaling pathways. These responses were reversed by folinic acid (FA), suggesting that OCM is a predominant target of MTX. Under FSS, MTX did not affect cell proliferation or pro-inflammatory gene expression. Exposure to FSS downregulated endothelial one carbon metabolism (OCM) as evidenced by decreased expression of key OCM genes and metabolites. We found that FSS significantly downregulated OCM and thereby rendered EC less susceptible to the effects of MTX treatment. The impact of shear stress on OCM suggested that MTX does not directly modulate endothelial function. The cardioprotective actions of MTX likely reflect direct actions on inflammatory cells and indirect benefit on the vascular endothelium.

The Role of Low-Dose Oral Methotrexate in Increasing Anti-TNF Drug Levels and Reducing Immunogenicity in IBD

Concomitant immunomodulation is utilised in combination with anti-TNF therapy for IBD primarily to increase drug levels and prevent anti-drug antibody formation. Whilst thiopurines have traditionally been the immunomodulator of choice in IBD populations, there are concerns regarding the long-term safety of the prolonged use of these agents: particularly an association with lymphoproliferative disorders. Given this, we have explored the existing literature on the use of low-dose oral methotrexate as an alternative immunomodulator for this indication. Although there is a lack of data directly comparing the efficacies of methotrexate and thiopurines as concomitant immunomodulators, the available literature supports the use of methotrexate in improving the pharmacokinetics of anti-TNF agents. Furthermore, low-dose oral methotrexate regimens appear to have comparable efficacies to higher-dose parenteral administration and are better tolerated. We suggest that clinicians should consider the use of low-dose oral methotrexate as an alternative to thiopurines when the primary purpose of concomitant immunomodulation is to improve anti-TNF pharmacokinetics.

Rhodiola rosea L. Extract, a Known Adaptogen, Evaluated in Experimental Arthritis

Rhodiola rosea L. extract (RSE) is mostly known for its adaptogen properties, but not for its antiarthritic activities, therefore monotherapy and combination with low-dose methotrexate (MTX) was studied. The collagen-induced arthritis (CIA) model was used to measure the functional score, and the change in hind paw volume (HPV). Both parameters had significant antiarthritic effects. Based on these preliminary results, an adjuvant arthritis (AA) model was further applied to assess another parameters. The experiment included these animal groups: healthy controls, untreated AA, AA administered with RSE (150 mg/kg b.w. daily, p.o.), AA administered by MTX (0.3 mg/kg b.w. twice a week, p.o.), and AA treated with the combination of RSE+MTX. The combination of RSE+MTX significantly reduced the HPV and increased the body weight. The combination significantly decreased HPV when compared to MTX monotherapy. The plasmatic levels of inflammatory markers (IL-6, IL-17A, MMP-9 and CRP) were significantly decreased by MTX+RSE treatment. The RSE monotherapy didn’t influence any of the inflammatory parameters studied. In CIA, the RSE monotherapy significantly decreased the arthritic parameters studied. In summary, the combination of RSE and sub-therapeutic MTX was significantly effective in AA by improving inflammatory and arthritic parameters.

Effect of bispecific B7H3 x CD19 CAR T cells on host CD19 expression and CAR T cell engraftment.

10043 Background: Our experience of B7H3 chimeric antigen receptor T cells (CAR-T) revealed modest engraftment (max 4.9 cells/uL) and no objective responses on first infusion. Previous CD19 CAR T cell trials have revealed that host B Cell CD19 can drive robust engraftment and persistence even in the absence of malignant CD19 expression. We therefore developed a bispecific B7H3xCD19 CAR T cell with the intent of using host CD19 expression to drive better engraftment of the B7H3-targeting CAR. Methods: Young patients with relapsed/refractory solid tumors (R/RST) were enrolled onto a Phase 1 trial (NCT04483778) to examine the safety of autologous T cells lentivirally transduced to express either or both scFV-IgG4hinge-CD28tm-4-1BB-zeta B7H3-specific and CD19-specific CARs. The B7H3 CAR construct contained the methotrexate resistance/selection cassette DHFRdm and the tracking/suicide construct EGFRt and the CD19 CAR construct containing the tracking/suicide construct HER2tg, allowing for differential CAR tracking. CAR T cells were cultured in low-dose methotrexate to select for B7H3 containing CAR T cells and limit exposure to monospecific CD19 CAR T cells. All patients received lymphodepleting fludarabine and cyclophosphamide prior to infusion of cryopreserved CAR-T at the prescribed dose level. The maximal tolerated dose or biologically effective dose (BED) was determined based upon observed toxicity through day 28 from initial CAR-T infusion and using a 3+3 statistical design. Results: 11 subjects (age 5-23, median 18 years) enrolled and received dose level (DL) 0B (0.5 x 106 TOTAL CAR-T/kg, n = 7) or DL1B (1 x 106 TOTAL CAR-T cells/kg, n = 4). One subject experienced dose limiting toxicities at DL1 of transaminitis, hyponatremia, worsening of a pericardial effusion and hypoxia. Most common toxicities were cytokine release syndrome (CRS) (n = 4, maximum CTCAE grade 2).No occurrence of ICANS was noted. Maximum total circulating CAR-T expansion on first infusion was 796.3 cells/uL and max B7H3 expansion was 374.2 cells/uL with 7/11 continuing with ongoing detection of CAR T cells in the peripheral blood at time of last follow up (21 days to 8 months). CAR engraftment was predominated by the B7H3 CAR single expressing CAR T cells in all subjects. All subjects developed B cell aplasia which is ongoing in 10/11 subjects at time of last check (range of 21 days to 8 months). Best overall response of Stable Disease was observed in 2 of the 11 subjects infused. Conclusions: B7H3xCD19 CAR T cells robustly engraft and expand in patients with R/RST and are safe, but despite ongoing detection of the CAR T cells, no objective responses were observed. It is likely that additional measures will be required to enhance the activity of CAR-T cells to achieve objective responses. STRIvE-02 Arm C will explore the addition of pembrolizumab post bispecific CAR infusion to evaluate the effect of PD1 blockade on anti-tumor activity. Clinical trial information: NCT04483778 .

EFFICACY AND SAFETY OF BTK INHIBITORS IN VITREORETINAL LYMPHOMA: A SINGLE‐CENTER RETROSPECTIVE ANALYSIS OF 24 PATIENTS

Purpose: Vitreoretinal lymphoma (VRL) is a rare subtype of lymphoma. The optimal treatment strategy is not yet defined. 60%–90% of VRL will progress to PCNSL. Therefore, central nervous system (CNS) prophylaxis for VRL patients is critical. Our previous studies have shown that BTK inhibitors monotherapy can replace repeated intravitreal injection of low-dose methotrexate, with rapid effect and a certain preventive value for the CNS. This study aimed to expand the sample size and extend the follow-up time to retrospectively analyze the efficacy and safety of BTK inhibitors in VRL. Method: A total of 24 VRL patients admitted to the Department of Hematology in Beijing Tongren Hospital from May 2020 to December 2022 were included. The clinical characteristics, treatment methods, treatment outcomes, survival status and treatment-related adverse reactions were retrospectively analyzed. Results: The median age was 62 years. There were 18 primary VRLs (PVRLs). The IL-10 in aqueous humor at baseline was significantly increased, and the IL-10/IL-6 ratio was greater than 1. There was no evidence of CNS involvement in 23 patients. All patients were treated with a BTK inhibitors (zanubrutinib 160 mg bid, or orelabrutinib 150 mg qd), and nine of them were also treated with intraocular injection of methotrexate. After 1 month of treatment, 21 patients had CR (87.5%) and 2 patients had PR (8.3%). The IL-10/IL-6 levels of aqueous humor were lower than 1 in all patients. The median duration of BTK inhibitors was 10 months. At a median follow-up of 17 months, 15 patients (62.5%) developed disease progression, including 11 with CNS infiltration and 4 with intraocular recurrence. The median PFS was 11.9 months, and the median OS was not reached. The 1-year PFS rate was 34% and the 1-year OS rate was 96%. The recurrence rate was 33.3% in the combined treatment group and 80.0% in the monotherapy group. Three patients died, all from CNS progression. BTK inhibitors were well tolerated, with grade 1-2 hypertension of 16.7%, grade 1 hypotension of 4.2%, grade 1 joint pain of 8.3%, grade 1 subcutaneous bleeding and ecchymosis of 25.0%. Four patients developed COVID-19 infection and BTK inhibitor medication was suspended. All patients had negative COVID-19 test within 2 weeks and did not develop significant pneumonia. Conclusion: BTK inhibitors showed rapid local control of VRL and were well tolerated. However, monotherapy with BTK inhibitors does not provide adequate central nervous system prophylaxis, and the combination of BTK inhibitors with other drugs, such as high-dose methotrexate, should be explored. The research was funded by: This work was supported by grants from the National Natural Science Foundation of China (grant No. 81873450, 82170181), Beijing Hospitals Authority Youth Programme (code: QML20200201), and Beijing Natural Science Foundation (No.7222027) to Liang Wang. Keywords: aggressive B-cell non-Hodgkin lymphoma, molecular targeted therapies No conflicts of interests pertinent to the abstract.

The Methotrexate Story: How did a Cancer Chemotherapeutic Agent Become a Disease-modifying Antirheumatic Drug

Abstract Weekly mini-pulse of low-dose methotrexate (LD-MTX) is presently the first-line conventional synthetic disease-modifying antirheumatic drug for the treatment of rheumatoid arthritis (RA) and several other systemic immunoinflammatory rheumatic diseases (SIRDs). Yet, most of the younger generation of rheumatologists around the world may be unaware of the interesting journey of MTX, from being an antifolate agent for use as cancer chemotherapy to becoming the mainstay of treatment for inflammatory arthritides and other SIRDs. This short essay narrates the journey of MTX from its precursor analog aminopterin to treat childhood leukemia, its name change from aminopterin to MTX, which became one of the major chemotherapeutic agents in oncology and then evolving as the mainstay of drug treatment for RA and other SIRDs. The seminal role of Gubner et al. from New York in 1953 in recognizing its steroid-sparing property in inflammatory diseases at doses much lower than that needed to treat cancer is highlighted.

Comparison of two doses of leucovorin in severe low-dose methotrexate toxicity – a randomized controlled trial

BackgroundLeucovorin (folinic acid) is a commonly used antidote for severe toxicity with low-dose methotrexate, but its optimum dose is unclear, varying from 15 to 25 mg every 6-h.MethodsOpen-label RCT included patients with severe low-dose (≤ 50 mg/week) methotrexate toxicity defined as WBC ≤ 2 × 10^9/L or platelet ≤ 50 × 10^9/L and randomized them to receive either usual (15 mg) or high-dose (25 mg) intravenous leucovorin given every 6-h. Primary outcome was mortality at 30-days and secondary outcomes were hematological recovery and mucositis recovery. Trial Registration number: CTRI/2019/09/021152.ResultsThirty-eight patients were included, most with underlying RA who had inadvertently overdosed MTX (taken daily instead of weekly). At randomization, the median white blood and platelet count were 0.8 × 10^9/L and 23.5 × 10^9/L. 19 patients each were randomized to receive either usual or high-dose leucovorin. Number (%) of deaths over 30-days was 8 (42) and 9 (47) in usual and high-dose leucovorin groups (Odds ratio 1.2, 95% CI 0.3 to 4.5, p = 0.74). On Kaplan–Meier, there was no significant difference in survival between the groups (hazard ratio 1.1, 95% CI 0.4 to 2.9, p = 0.84). On multivariable cox-regression, serum albumin was the only predictor of survival (hazard ratio 0.3, 95% CI 0.1 to 0.9, p = 0.02). There was no significant difference in hematological or mucositis recovery between the two groups.ConclusionThere was no significant difference in survival or time-to hematological recovery between the two doses of leucovorin. Severe low-dose methotrexate toxicity carried a significant mortality.

L-carnitine and Zinc supplementation impedes intestinal damage in methotrexate-treated adjuvant-induced arthritis rats: Reinstating enterocyte proliferation and trace elements

BackgroundMethotrexate (MTX), a folic acid analogue, is used as a first-line treatment for rheumatoid arthritis (RA) since it has more therapeutic mechanisms than any other drug. Being an undeniable drug for the treatment of arthritis, even low-dose MTX provokes intestinal toxicity as a primary adverse effect and does not revive an anti-inflammatory element. Thus, our study aims to elucidate the anti-arthritic and prophylactic activity of supplements L-carnitine (L) and zinc (Z) against MTX-mediated intestinal damage in arthritis rats. MethodsThe rats were assessed for arthritic parameters such as body weight, paw volume, x-ray scan, and serum trace elements level. To analyze the toxic effects of MTX in the rats, intestine pH, mucosal weight, digestive enzymes, myeloperoxidase, histopathological, and immunohistochemical analysis were performed. ResultsOur study demonstrated that the arthritic parameters have shown that MTX has an ameliorative effect on arthritic rats. Besides, our findings showed that low-dose MTX (2.5 mg/kg b.w.) given once a week for two weeks during arthritis treatment had toxic effects in the rat's intestine, as evidenced by changes in intestine pH and mucosal weight, decreased digestive enzymes, increased MPO, and degenerative changes in histopathological analysis. Concurrent therapy of LZ with MTX, on the other hand, restored the modifications in these parameters. ConclusionMTX in combination with LZ effectively manages arthritis than monotherapy and significantly prevents MTX-induced intestinal damage in arthritis rats. Thus, LZ could be used as an improved therapeutic and safety for MTX-instigated intestinal damage during arthritis treatments. Therefore, our combination of L-carnitine and zinc with MTX would be promising prophylactic activity for arthritis patients.

Oral vinorelbine in young patients with desmoid-type fibromatosis.

Desmoid-type fibromatosis are rare intermediate tumors in children and adolescents. Owing to local aggressiveness and relapse, systemic treatment for symptomatic advanced or progressive forms is recommended. Following promising results in adult patients, oral vinorelbine is investigated in young patients. A retrospective review of young patients (<25 years old) with advanced or progressive desmoid type fibromatosis treated with oral vinorelbine in eight large centers of the Société Française des Cancers de l'Enfant was performed. In addition to tumor assessment according to RECIST 1.1, pre-treatment and during-treatment imagery were reviewed centrally to assess tumor volume and estimate fibrosis score through the change in percentage in hypoT2 signal intensity. From 2005 to 2020, 24 patients (median age 13.9 years [range, 1.0-23.0]) received oral vinorelbine. Median number of prior systemic lines of treatment was 1 (range, 0-2), mainly based on intravenous low dose methotrexate and vinblastine. Before vinorelbine initiation, all patients had a progressive disease: radiological for 19, radiological and clinical (pain) for three and only clinical for two. Oral vinorelbine was delivered for a median duration of 12 months (range, 1-42). The toxicity profile was favorable, with no grade 3-4 event. Overall response estimated on 23 evaluable patients according to RECIST 1.1 criteria was three partial responses (13%), 18 stabilization (78%) and two progressive disease (9%). Overall progression-free survival was 89.3% (95% confidential intervals 75.2-100) at 24 months. Four stable tumors according to standard RECIST criteria displayed a partial response with > 65% tumor volume reduction. Among 21 informative patients, the estimated fibrosis score decreased for 15 patients, was stable for four patients and increased for two patients. Oral vinorelbine seems to be effective to control advanced or progressive desmoid type fibromatosis in young patients, with a well-tolerated profile. These results support testing this drug as first-line alone or in combination to improve response rate while preserving quality of life.

P011 Rituximab and COVID-19 vaccines; are they fit for purpose?

Abstract Background/Aims Since the COVID-19 outbreak the rheumatology community have been concerned about the risk of SARS-CoV-2 infection in patients prescribed immunosuppressing medications. Data suggests that patients receiving Rrtuximab are at increased risk of developing severe outcomes from COVID-19 (1). In our unit all patients receiving rituximab were selected to receive a targeted vaccination and booster programme with all patients receiving at least 2 vaccinations and up to 3 booster vaccinations. We studied the efficacy of the COVID-19 vaccines in rituximab patients, by checking the the Roche Elecsys Anti-SARS-CoV-2-S (Spike) IgG/IgM total antibody levels post vaccination. Our aim was to assess the vaccination response in patients receiving rituximab and to offer advice on continued shielding or alternatively passive immunization with tixagevimab/cilgavimab in those patients who did not mount a response. Methods Taking 39 patients currently on rituximab therapy, we measured Anti-SARS-CoV-2-S (Spike) antibody levels post vaccination. We recorded whether the test was positive or negative, and the numerical result. We recorded rituximab dates of administration and dates of vaccines. We also recorded diagnosis, co-prescribed DMARDs, immunoglobulin levels, white cell and lymphocyte counts. We took record of whether or not the patient subsequently contracted COVID-19, required a hospital admission, ICU or died. Results Of our 39 patients, 21 had Anti-SARS-CoV-2-S (Spike) antibody levels checked. Of these patients, 7 (33%) had a negative spike protein result. Of the patients with a positive result, 8 (38%) had an antibody level between 0-250U/ML, and only 6 (28.6%) had a level &amp;gt;250U/ML (The manufacturer advises that a level above 0.8U/ML is a positive result). Of patients with a negative result, 1 patient had received 3 vaccines, 5 patients had received 4, and 1 patient had 5. All of the patients had received a vaccine &amp;gt;4 weeks prior to receiving the drug. Two patients were co-prescribed Belimumab, 3 were co-prescribed low-dose methotrexate and 2 were not on additional disease modifying agents. The diagnoses of these patients were, 2 patients with SLE, 4 with SPRA, and 1 MPO Vasculitis. There were no significant findings in lymphocyte count, white cell count or immunoglobulin levels. Conclusion These findings suggest that our current COVID-19 vaccination and booster programme may not provide adequate response in patients receiving rituximab therapy. Despite this being a small cohort, these results show that 33% of patients have not mounted a vaccine response and this is concerning. We suggest that vaccine response should be checked in all patients receiving rituximab therapy and those patients who do not mount a vaccine response should be offered passive immunity and advised of possible additional risks regarding COVID-19 exposure. Disclosure S.K. Stewart: None. A. Pendleton: None.

Platelet Rich Plasma and Adipose-Derived Mesenchymal Stem Cells Mitigate Methotrexate-Induced Nephrotoxicity in Rat via Nrf2/Pparγ/HO-1 and NF-Κb/Keap1/Caspase-3 Signaling Pathways: Oxidative Stress and Apoptosis Interplay.

the nephrotoxicity of methotrexate (MTX) is observed in high-dose therapy. Moreover, low-dose MTX therapy for rheumatic diseases is debatable and claimed to cause renal impairment. This study aimed at studying the effect of methotrexate in repeated low doses on rat kidneys and assessing the efficacy of adipose-derived mesenchymal stem cells (AD-MSCs) and platelet rich plasma (PRP) for attenuating this effect. Forty-two male Wistar rats were used, 10 rats were donors of AD-MSCs and PRP, 8 rats served as control, and the remaining rats were subjected to induction of nephrotoxicity by MTX intraperitoneal injection once weekly for successive 8 weeks and then assigned into 3 groups of 8 animals each: Group II: received MTX only. Group III: received MTX + PRP. Group IV: received MTX + AD-MSCs. After one month, rats were anaesthetized, serum-sampled, and renal tissue removed for biochemical, histological, and ultrastructural evaluation. there was significant tubular degeneration, glomerulosclerosis, fibrosis, decreased renal index, along with increased levels of urea and creatinine in the MTX group compared to the control group. Immunohistochemical expression of caspase-3 and iNOS in the renal tissue was significantly increased in group II compared to groups III and IV. Biochemical results revealed higher tissue malondialdehyde (MDA) concentration in the MTX-injected group which decreased significantly in co-treatment with either AD-MSC or PRP + MTX. MSC promoted the activation of the Nrf2/PPARγ/HO-1 and NF-κB/Keap1/caspase-3 pathways, increased antioxidant enzyme activities, reduced lipid peroxidation levels, and alleviated oxidative damage and apoptosis. PRP showed therapeutic effects and molecular mechanisms similar to MSC. Furthermore, MSC and PRP treatment significantly reduced MTX-induced upregulation of the pro-inflammatory (NF-κB, interleukin-1ß, and TNF-α), oxidative stress (Nrf-2, hemoxygenase-1, glutathione, and malondialdehyde), and nitrosative stress (iNOS) markers in the kidney. repeated administration of low-dose MTX resulted in massive renal tissue toxicity and deterioration of renal function in rats which proved to be attenuated by PRP and AD-MSCs through their anti-inflammatory, anti-apoptotic and anti-fibrotic properties.

Low-dose methotrexate-induced renal failure in a patient with ectopic pregnancy: a case report

BackgroundMethotrexate is an anticancer drug from the antimetabolite class. It is also used in gynecology and obstetrics for the medical treatment of ectopic pregnancies. Low-dose methotrexate-induced adverse toxic effects are rare. We report a case of toxic effect associated with severe renal insufficiency induced by LD-MTX (Low-Dose Methotrexate) for ectopic pregnancy.Case presentationA 46-year-old Chinese woman was in an operation for an ectopic pregnancy of tubal interstitial pregnancy. The embryo villus was so little that we were not sure if it was evacuated, then it was followed with 50 mg methotrexate injection of intramuscular adjacent the uterine horn in the operation. 48 hour later after injection the patient presented with renal failure. The personalized genetic testing showed that MTHFR (677C > T) and ABCB1 (3435T > C) were detected. Gradually, the symptoms improved after calcium leucovorin (CF) rescue, continuous renal replacement therapy (CRRT), promoting blood system regeneration, and multiple supportive treatments.ConclusionsWhen toxic effects are suspected, detecting the polymorphisms of an MTHFR gene and monitoring MTX concentration in blood could assist us to formulate individualized and active treatments. The management should be multidisciplinary and as much as possible within an intensive care unit.