Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, Tyne and Wear NE9 6SX, UK.
Clin Rheumatol. 2010 Oct;29(10):1093-8. doi: 10.1007/s10067-010-1500-9. Epub 2010 Jun 11.
Oral methotrexate is the benchmark against which other disease-modifying anti rheumatic drugs are measured. The use of parenteral methotrexate for those failing to tolerate or respond to oral therapy is accepted, but indications for its use and its place in the therapeutic ladder have not been fully investigated. We assessed the use of parenteral methotrexate (MTX) in our rheumatoid arthritis (RA) population and compared the characteristics of these patients to a matched group of those on oral therapy. We compared response rates to each approach using DAS 28 scores, ESR and visual analogue scales. Inferences on costs of parenteral therapy were made and predictors of response defined. We found that 10% of our total RA patient population were on parenteral methotrexate, having failed to tolerate or respond to oral therapy. Seventy-five percent of these met the criteria for the use of anti-tumour necrosis factor (TNF) agents. Overall response rates were equivalent to those obtained by responders to oral MTX. Patients on parenteral therapy were younger and were more likely to have extreme values of body mass index (BMI) than those on oral therapy. The approach was economically viable, although many patients unnecessarily attended hospital to receive their injections. We advocate consideration of parenteral MTX in all RA patients unresponsive to oral therapy prior to treatment with anti-TNF therapy. Response to parenteral therapy can be predicted by low BMI (below 22 kg/m(2)), possibly as a result of malabsorption, or by high BMI (over 30) as a result of gastrointestinal intolerance. A mechanism to deliver this option through self-administration in the community should be encouraged.
口服甲氨蝶呤是衡量其他疾病修正抗风湿药物的基准。对于不能耐受或对口服治疗无反应的患者，使用注射用甲氨蝶呤是可以接受的，但它的使用指征及其在治疗阶梯中的地位尚未得到充分研究。我们评估了我们的类风湿关节炎（RA）患者群体中使用注射用甲氨蝶呤（MTX）的情况，并将这些患者的特征与接受口服治疗的匹配组进行了比较。我们使用 DAS28 评分、ESR 和视觉模拟量表比较了每种方法的反应率。对注射治疗的成本进行了推断，并确定了反应的预测因素。我们发现，我们的 RA 患者群体中，有 10%的患者因不能耐受或对口服治疗无反应而接受了注射用甲氨蝶呤治疗。其中 75%的患者符合使用抗肿瘤坏死因子（TNF）药物的标准。总体反应率与口服 MTX 应答者的反应率相当。接受注射治疗的患者年龄较小，且身体质量指数（BMI）值极端的可能性高于口服治疗者。尽管许多患者不必要地到医院接受注射，但这种方法在经济上是可行的。我们主张在使用抗 TNF 治疗之前，对所有对口服治疗无反应的 RA 患者考虑使用注射用 MTX。通过低 BMI（低于 22kg/m2）可预测对注射治疗的反应，这可能是由于吸收不良所致，或者通过高 BMI（超过 30）可预测由于胃肠道不耐受所致。应鼓励通过社区自我管理来提供这种选择。
