Rheumatology Advance Access originally published online on March 9, 2009
Rheumatology 2009 48(5):569-572; doi:10.1093/rheumatology/kep023
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Liver fibrosis in patients with psoriasis and psoriatic arthritis on long-term, high cumulative dose methotrexate therapy
1Department of Rheumatology, Harrogate District Hospital, Harrogate, 2Department of Rheumatology, Leeds General Infirmary, Leeds, 3Department of Dermatology, Harrogate District Hospital, Harrogate, 4Department of Dermatology, Leeds General Infirmary, Leeds and 5Norgine Limited International, Middlesex, UK.
Correspondence to: Karen Lindsay, 27 Broster Avenue, Guardhouse, Keighley, West Yorkshire BD22 6JE, UK. E-mail: karen.lindsay{at}anhst.nhs.uk
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Abstract |
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Objectives. Dermatologists and rheumatologists have differed in their use of serial liver biopsy and liver function tests (LFT) to monitor the risk of hepatic fibrosis in long-term MTX therapy. It is judged safe to monitor LFT only in RA. Whilst there are few studies in PsA to justify this approach, it is widely used in rheumatology practice. The study aimed to assess prevalence of hepatic fibrosis in both psoriasis and PsA patients on long-term MTX therapy.
Methods. A prospective study of 54 patients with psoriatic disease had a liver biopsy according to dermatology guidelines on long-term MTX treatment with full assessment of risk factors. Previously, monitoring these patients was in accordance with ACR guidelines with 3-monthly LFT.
Results. MTX treatment duration was a mean of 6.9 years, with a mean cumulative dose of 4396 mg. There were no cases of advanced fibrosis or of cirrhosis and mild early fibrosis in 11 (22%) patients. The presence of early mild changes was related to the number of risk factors that the patient had for hepatic fibrosis [also the risk factors for non-alcoholic steatohepatitis (NASH)]. Pro-collagen 3 N-terminal peptide (PIIINP) was unhelpful in PsA and frequently elevated despite normal liver biopsy.
Conclusions. Despite other risk factors for NASH, monitoring for hepatic fibrosis using serial liver function and ACR guidelines tests alone as in RA appears safe in psoriasis and PsA. Liver biopsy ought to be considered to assess the liver if LFT are persistently elevated. PIIINP is misleading in active PsA.
KEY WORDS: Liver fibrosis, Psoriasis, Psoriatic arthritis, Methotrexate therapy, Safety incidence, Liver biopsy
Submitted 31 December 2007; Accepted 19 January 2009
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