Prado Mario B, Adiao Karen Joy B
Department of Physiology, College of Medicine, University of the Philippines, Manila, Philippines.
Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines, Manila, Philippines.
Acta Neurol Belg. 2023 Oct;123(5):1679-1691. doi: 10.1007/s13760-023-02242-w. Epub 2023 Mar 27.
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.
当前的重症肌无力指南推荐使用硫唑嘌呤作为一线类固醇替代药物。然而，由于其成本高昂，在发展中国家，硫唑嘌呤的依从性较低。为了确定较便宜的甲氨蝶呤作为替代免疫抑制剂的疗效和安全性，检索了Medline/Pubmed、Embase和Cochrane数据库及参考文献，以查找使用以下检索词的临床试验和观察性研究：“重症肌无力或重症肌无力或抗乙酰胆碱受体抗体阳性的重症肌无力或抗肌肉特异性激酶抗体重症肌无力或MG”以及“甲氨蝶呤”。在78篇可能的文章中，仅根据以下纳入标准选择了4篇：研究对象：全身性重症肌无力患者；干预措施：甲氨蝶呤；结局指标：有效性、类固醇替代疗效和不良反应。两项临床试验和一项观察性研究指出，给予甲氨蝶呤的患者在不同的重症肌无力结局方面有改善。虽然一项随机对照临床试验得出结论，甲氨蝶呤没有类固醇替代益处，但一项单盲临床试验证实，从使用第10个月起，甲氨蝶呤作为类固醇替代药物比硫唑嘌呤更好。不良反应很少见，最常见的主诉是非特异性疼痛和转氨酶升高。基于现有证据，在发展中国家，甲氨蝶呤作为类固醇替代药物可能是硫唑嘌呤的一种安全有效的替代品。
