Erickson A R, Reddy V, Vogelgesang S A, West S G
Department of Medicine, Fitzsimons Army Medical Center, Aurora, CO 80045, USA.
Arthritis Rheum. 1995 Aug;38(8):1115-9. doi: 10.1002/art.1780380814.
To test the usefulness and cost savings resulting from application of the new American College of Rheumatology (ACR) guidelines for assessing the risk for the development of clinically significant liver disease in rheumatoid arthritis (RA) patients treated with methotrexate (MTX).
One-hundred twelve MTX-treated RA patients were prospectively followed up for MTX hepatotoxicity and underwent liver biopsies according to modified guidelines of the Psoriatic Task Force (PTF). All biopsies were graded according to the Roenigk classification. The new ACR recommendations were then retrospectively applied to test their usefulness and cost-effectiveness in this cohort.
Based on the PTF guidelines, 66 patients underwent liver biopsies; a total of 110 liver biopsies were performed. Two patients had biopsy-related complications. Five patients were found to have Roenigk grade IIIB or IV histologic abnormalities. The total cost for this group was $111,380. Applying the new ACR criteria, only 15 patients would have undergone liver biopsies; there would have been a total of 18 biopsies, with no complications. Four of the 5 patients with Roenigk grade IIIB or IV liver abnormalities would have been identified. One patient with insulin-dependent diabetes mellitus (IDDM) who was found to have cirrhosis (Roenigk grade IV) on liver biopsy as a result of use of the PTF guidelines would have been missed with use of the ACR guidelines. The total cost for the group receiving biopsies based on the ACR guidelines would have been $16,956. Overall, the new ACR guidelines had 80% sensitivity and 82% specificity and resulted in a cost savings of $1,430 per patient.
The new ACR guidelines on MTX monitoring and biopsy surveillance appear to be clinically useful and result in considerable cost savings. However, 1 IDDM patient with significant liver histologic abnormalities would have been missed. We suggest that IDDM be added to the ACR guidelines as a risk factor for MTX hepatotoxicity.
检验应用美国风湿病学会（ACR）新指南评估接受甲氨蝶呤（MTX）治疗的类风湿关节炎（RA）患者发生具有临床意义的肝脏疾病风险的实用性及成本节约情况。
对112例接受MTX治疗的RA患者进行前瞻性随访，观察MTX肝毒性，并根据银屑病工作组（PTF）的改良指南进行肝活检。所有活检标本均按照罗宁克分类法进行分级。然后回顾性应用ACR新推荐，以检验其在该队列中的实用性和成本效益。
根据PTF指南，66例患者接受了肝活检；共进行了110次肝活检。2例患者出现活检相关并发症。5例患者被发现有罗宁克III B级或IV级组织学异常。该组的总费用为111,380美元。应用ACR新标准，只有15例患者会接受肝活检；总共会进行18次活检，且无并发症。5例罗宁克III B级或IV级肝脏异常患者中有4例会被识别出来。1例因使用PTF指南在肝活检中被发现患有肝硬化（罗宁克IV级）的胰岛素依赖型糖尿病（IDDM）患者，若使用ACR指南则会被漏诊。根据ACR指南接受活检的组的总费用为16,956美元。总体而言，ACR新指南的敏感性为80%，特异性为82%，每位患者可节约成本1,430美元。
ACR关于MTX监测和活检监测的新指南似乎具有临床实用性，并能显著节约成本。然而，1例具有明显肝脏组织学异常的IDDM患者会被漏诊。我们建议将IDDM作为MTX肝毒性的危险因素添加到ACR指南中。
