Abstract
Objective
We assessed the effect of folic acid (FA) on the pharmacokinetics and pharmacodynamics of low-dose oral methotrexate (MTX) during the remission-induction phase of psoriasis treatment.
Methods
In a 32-week, open-label, two-way cross-over study, patients (n = 20, seven men, aged 35–70 years) with moderate-to-severe plaque psoriasis were randomly assigned to receive MTX plus FA (20 mg/week) for 16 weeks followed by MTX monotherapy (three doses of MTX separated by 12-h intervals once a week) for an additional 16 weeks (treatment arm A, n = 10) or to receive the opposite sequence of treatments (arm B, n = 10). Dosing of MTX was individualised with the help of pre-study evaluation of plasma MTX pharmacokinetics. The Psoriasis Area and Severity Index (PASI), biochemistry and haematology tests and erythrocyte concentration of MTX polyglutamates (MTXPG) were evaluated throughout the study.
Results
In arms A and B, the mean (range) concentrations of MTXPG (nmol/L) were comparable [week 16: 96.2 (32.0–157) vs. 111 (73.7–175), P = 0.32; week 32: 103 (55.8–173) vs. 83.6 (27.4–129), P = 0.24]. After 16 weeks, the mean±SEM PASI decreased from 20.1 ± 2.1 to 8.8 ± 1.3 in arm A, while a greater reduction from 27.2 ± 2.1 to 5.1 ± 1.0 occurred in arm B (P < 0.001). Positive correlations were found between the percent improvement in PASI at week 16 and the ratios of the concentration of MTXPG to plasma folate (rho = 0.59, P = 0.008) or RBC folate concentration (rho = 0.56, P = 0.013). Due to an accelerated decline in PASI in arm A and a trend to its worsening in arm B after crossing over of treatments, the mean absolute PASI scores in both arms were comparable at week 32.
Conclusion
The antipsoriatic effect of MTX during the remission-induction phase of treatment is influenced by folate status and may be significantly less if combined treatment with FA is used, irrespective of pre-treatment folate levels. The individual tailoring of MTX dosing needs further attention because the mean percent PASI improvement from baseline was 83% and the inter-patient variability in response was low after 16 weeks of monotherapy with MTX.
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References
Naldi L, Griffiths CE (2005) Traditional therapies in the management of moderate to severe chronic plaque psoriasis: an assessment of the benefits and risks. Br J Dermatol 152:597–615
Haustein UF, Rytter M (2000) Methotrexate in psoriasis: 26 years’ experience with low-dose long-term treatment. JEADV J Eur Acad Dermatol Venereol 14:382–388
Grim J, Chladek J, Martinkova J (2003) J Pharmacokinetics and pharmacodynamics of methotrexate in non-neoplastic diseases. Clin Pharmacokinet 42:139–151
Chladek J, Grim J, Martinkova J et al (2002) Pharmacokinetics and pharmacodynamics of low-dose methotrexate in the treatment of psoriasis. Br J Clin Pharmacol 54:147–156
van Ede AE, Laan RF, Blom HJ et al (2002) Homocysteine and folate status in methotrexate-treated patients with rheumatoid arthritis. Rheumatology (Oxford) 41:658–665
Hornung N, Ellingsen T, Stengaard-Pedersen K, Poulsen JH (2004) Folate, homocysteine, and cobalamin status in patients with rheumatoid arthritis treated with methotrexate, and the effect of low dose folic acid supplement. J Rheumatol 31:2374–2381
Morgan SL, Baggott JE, Lee JY, Alarcón GS (1998) Folic acid supplementation prevents deficient blood folate levels and hyperhomocysteinemia during longterm, low dose methotrexate therapy for rheumatoid arthritis: implications for cardiovascular disease prevention. J Rheumatol 25:441–446
Whittle SL, Hughes RA (2004) Folate supplementation and methotrexate treatment in rheumatoid arthritis: a review. Rheumatology (Oxford) 43:267–271
Strober BE, Menon K (2005) Folate supplementation during methotrexate therapy for patients with psoriasis. J Am Acad Dermatol 53:652–659
Salim A, Tan E, Ilchyshyn A, Berth-Jones J (2006) Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial. Br J Dermatol 154:1169–1174
Boffa MJ (2005) Methotrexate for psoriasis: current European practice. A postal survey. JEADV J Eur Acad Dermatol Venereol 19:196–202
Chladek J, Grim J, Martinkova J et al (2002) Pharmacokinetics and pharmacodynamics of low-dose methotrexate in the treatment of psoriasis. Br J Clin Pharmacol 54:147–156
Dervieux T, Orentas Lein D, Marcelletti J et al (2003) HPLC determination of erythrocyte methotrexate polyglutamates after low-dose methotrexate therapy in patients with rheumatoid arthritis. Clin Chem 49:1632–1641
Schroder H, Fogh K (1988) Methotrexate and its polyglutamate derivatives in erythrocytes during and after weekly low-dose oral methotrexate therapy of children with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 21:145–149
Da Costa M, Iqbal MP (1981) The transport and accumulation of methotrexate in human erythrocytes. Cancer 48:2427–2432
Chladek J, Grim J, Martinkova J et al (2005) Low-dose methotrexate pharmacokinetics and pharmacodynamics in the therapy of severe psoriasis. Basic Clin Pharmacol Toxicol 96:247–248
Ranganathan P, McLeod HL (2006) Methotrexate pharmacogenetics: the first step toward individualized therapy in rheumatoid arthritis. Arthritis Rheum 54:1366–1377
Kurnik D, Loebstein R, Fishbein E et al (2003) Bioavailability of oral vs. subcutaneous low-dose methotrexate in patients with Crohn’s disease. Aliment Pharmacol Ther 18:57–63
Bressolle F, Kinowski JM, Morel J et al (2000) Folic acid alters methotrexate availability in patients with rheumatoid arthritis. J Rheumatol 27:2110–2114
Lebbe C, Beyeler C, Gerber NJ, Reichen J (1994) Intraindividual variability of the bioavailability of low dose methotrexate after oral administration in rheumatoid arthritis. Ann Rheum Dis 53:475–477
Kremer JM, Petrillo GF, Hamilton RA (1995) Pharmacokinetics and renal function in patients with rheumatoid arthritis receiving a standard dose of oral weekly methotrexate: association with significant decreases in creatinine clearance and renal clearance of the drug after 6 months of therapy. J Rheumatol 22:38–40
Chládek J, Martínková J, Šimková M et al (1998) Pharmacokinetics of low doses of methotrexate in patients with psoriasis over the early period of disease. Eur J Clin Pharmacol 53:437–444
Strober BE, Siu K, Menon K (2006) Conventional systemic agents for psoriasis. A systematic review. J Rheumatol 33:1442–1446
Heydendael VM, Spuls PI, Opmeer BC et al (2003) Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis. N Engl J Med 349:658–665
Guinotte CL, Burns MG, Axume JA et al (2003) Methylenetetrahydrofolate reductase 677C->T variant modulates folate status response to controlled folate intakes in young women. J Nutr 133:1272–1280
Ede AE, Laan RF, Rood MJ et al (2001) Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 44:1515–1524
Morgan SL, Baggott JE, Vaughn WH et al (1994) Supplementation with folic acid during methotrexate therapy for rheumatoid arthritis. A double-blind, placebo-controlled trial. Ann Intern Med 121:833–841
Saporito FC, Menter MA (2004) Methotrexate and psoriasis in the era of new biologic agents. J Am Acad Dermatol 50(2):301–309
Acknowledgements
The study was supported by grants from the Czech Ministry of Health no. NR7947-3/2004 and Czech Ministry of Education and Youth MSM 0021620820 and 1P05OC066.
Statement of competing interests
All authors (Jaroslav Chladek, Marie Simkova, Jaroslava Vaneckova, Milos Hroch, Jirina Chladkova, Jirina Martínková, Jaroslava Vávrová, Martin Beránek) declare that they have no competing interests.
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Chládek, J., Simková, M., Vanecková, J. et al. The effect of folic acid supplementation on the pharmacokinetics and pharmacodynamics of oral methotrexate during the remission-induction period of treatment for moderate-to-severe plaque psoriasis. Eur J Clin Pharmacol 64, 347–355 (2008). https://doi.org/10.1007/s00228-007-0442-x
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DOI: https://doi.org/10.1007/s00228-007-0442-x