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A Clinical Approach to the Use of Methotrexate for Sarcoidosis Thorax: First Published As 10.1136/Thx.54.8.742 on 1 August 1999

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A Clinical Approach to the Use of Methotrexate for Sarcoidosis Thorax: First Published As 10.1136/Thx.54.8.742 on 1 August 1999 742 Thorax 1999;54:742–746 A clinical approach to the use of methotrexate for sarcoidosis Thorax: first published as 10.1136/thx.54.8.742 on 1 August 1999. Downloaded from Robert P Baughman, Elyse E Lower The management of patients with sarcoidosis safety.18–21 In these patients the toxicity from has been the subject of many papers in this1 methotrexate was predictable and guidelines and other journals.2–5 The large number of for monitoring the agent became available.22 papers are, in part, because of the diYculty in We became interested in the use of metho- defining who should be treated for this disease trexate for sarcoidosis over 10 years ago. The and with what. The most commonly used original patients had been on corticosteroids pharmaceutical class for sarcoidosis has been for many years (range 2–23 years, median 5 corticosteroids, both topically and years) and wished to try an alternative agent.23 systemically.6 The use of systemic steroids for In some cases we had patients who refused to sarcoidosis was the subject of a trial by the take prednisone again despite advancing dis- British Thoracic Society1 which concluded that ease. In our first 15 patients it was clear that there were some patients who required no methotrexate was an agent that took some time treatment and some who would need immedi- to be eVective. For the majority of patients ate treatment because of the severity of the dis- objective evidence of response to treatment ease. In between was a group of patients with could take as long as six months, although sub- persistent disease who appeared to benefit jective improvement was sometimes seen from treatment with corticosteroids. One of the sooner. Thus, the recommendation that the points made was that some patients needed drug should be withdrawn after six months treatment for long periods of time. meant that patients would be perceived as not The term “chronic sarcoidosis” has been responding simply because they had not used by Dr Geraint James to describe patients received the drug for suYcient time. with disease for more than two years.7 He noted Because of this clinical response we studied that some features of sarcoidosis such as lupus the inflammatory response to methotrexate pernio and neurological disease were associ- compared with prednisone in patients with ated with a low rate of remission, while other sarcoidosis.24 In sarcoidosis the researcher has features such as erythema nodosum were asso- the unique opportunity to examine the inflam- ciated with a high resolution rate by two years. matory cells in the organ aVected by the http://thorax.bmj.com/ Several other manifestations of the disease have disease. Bronchoalveolar lavage (BAL) has been associated with chronic disease: bone provided a large amount of information cysts, cor pulmonale, pulmonary fibrosis,8 and regarding interstitial lung diseases, especially nephrolithiasis.9 Based on the type and dura- sarcoidosis.25 The BAL fluid of a patient with tion of symptoms one can classify patients as active sarcoidosis usually contains an increased acute or chronic.10 A third group is also percentage of T lymphocytes, usually CD4+ evident—namely, those who are refractory to cells.26 In addition, the alveolar macrophages corticosteroid therapy. This includes some retrieved by BAL from patients with sarcoido- neurosarcoidosis patients, patients who de- sis are activated and release various products on September 27, 2021 by guest. Protected copyright. velop organ failure, and those who die despite including hydrogen peroxide and tumour corticosteroid treatment.11 12 Treatment for necrosis factor (TNF).27 28 In our study patients sarcoidosis is often dependent on the patient’s with active sarcoidosis were treated with either own manifestation. A patient with anterior prednisone or methotrexate and the clinical uveitis may be a candidate for topical steroids and inflammatory response was measured. alone, but a patient with neurological disease Patients were treated for at least six months may need chronic high dose corticosteroids to with either agent. There was a significant control the disease.13 Patients in the chronic improvement in the vital capacity over this time category have been interested for years in period for both drugs. The increased number taking alternatives to corticosteroids. Fortu- of lymphocytes found in the BAL fluid of nately, a group of agents has been used as ster- patients with active sarcoidosis fell significantly oid sparing agents in sarcoidosis.10 14 15 We will with treatment with either agent, and the discuss the use of one of these, methotrexate. CD4:CD8 ratio became closer to normal The first report of methotrexate in the treat- (table 1). The spontaneous release of TNF was ment of sarcoidosis was over 30 years ago.16 again seen from the alveolar macrophages Department of The drug was initially used for chronic cases. retrieved by BAL in patients with active Internal Medicine, University of Although it was sometimes eVective, clinicians sarcoidosis. This also fell with treatment in Cincinnati Medical would usually limit treatment to six months both the prednisone and methotrexate Center, Cincinnati, because of concerns about the toxic eVects of groups.24 This study was neither blinded nor Ohio 45267-0564, USA the agent, particularly bone marrow suppres- randomised. Some patients treated with metho- R P Baughman sion and hepatotoxicity.17 Methotrexate has trexate also received low dose corticosteroids. EELower been used widely in rheumatoid arthritis and Several studies have demonstrated the value Correspondence to: experience with the agent in both adults and of methotrexate in patients with refractory dis- Dr R P Baughman. children has demonstrated its relative ease. These are summarised in table 2. Many of A clinical approach to the use of methotrexate for sarcoidosis 743 Table 1 Mean (SE) results of methotrexate versus prednisone in sarcoidosis24 trexate. In some patients we did not see a response but were able to reduce the dosage of Thorax: first published as 10.1136/thx.54.8.742 on 1 August 1999. Downloaded from Methotrexate Prednisone prednisone. Our overall response rate in that Before After Before After study was 66%. In a follow up report of 209 treatment treatment treatment treatment patients treated for at least six months with Vital capacity (l) 2.4 (0.14) 2.8 (0.18)† 2.5 (0.14) 3.1 (0.18)† methotrexate 52% appeared to be in remission BAL lymphocyte (%) 37 (3.4) 16 (2.7)† 30 (3.5) 16 (2.7)† and 16% were stable on methotrexate with or BAL lymphocyte CD4:CD8 7.4 (2.69) 4.0 (1.90) 7.3 (1.52) 3.3 (0.67) without low dose prednisone.33 In a separate Macrophage TNF release (units/106 cells) 111 (44.4) 24 (15.4)‡ 89 (29.2) 18 (9.2)‡ report patients with neurosarcoidosis who were treated with various agents were analysed. BAL = bronchoalveolar lavage; TNF = tumour necrosis factor. Methotrexate was given to 28 of these patients †p<0.001, ‡p<0.05 versus before treatment. and a response was seen in 61%.13 these reports concerned a few cases with The long standing use of methotrexate for chronic disease. The most common manifesta- malignancy, rheumatoid arthritis, and psoriasis tions include skin disease, especially lupus has given an understanding of the toxicity of pernio. The response rate for skin disease the drug. There appear to be four major appears high. The patients with lung disease categories of toxicity: haematological, gastro- are less likely to respond, with about half of intestinal, pulmonary, and hepatic.18 34 There patients reporting some response. One diY- does not seem to be a particular toxicity in sar- culty with these case reports is the fact that one coidosis patients that has not been reported in does not have a sense of how many cases did the other groups, although the frequency of not respond to treatment. One group reported haematological and hepatic toxicity may be on their use of methotrexate with both cortico- higher in sarcoidosis patients because of steroids and cyclosporin.29 Although there was underlying organ involvement. a good clinical response, it was not clear how Sarcoidosis can aVect the bone marrow.35–37 much the methotrexate contributed to the The toxicity can be the result of mechanical eVectiveness. It was the best tolerated of the disruption of the marrow by granulomas as three drugs given. well as an indirect eVect from the various In a study of paediatric sarcoidosis, children cytokines released. Serial studies of patients received methotrexate following a strict with sarcoidosis have shown one or more hae- protocol.30 Corticosteroids were used for the matological abnormalities in over half of the first weeks only in six of seven cases. They were cases.35 38 Lymphopenia is the most common treated with methotrexate for one year and the abnormality. Significant anaemia is seen in clinical response was scored using a composite 20% of cases and leukopenia occurs in 10% of of the various symptoms encountered. The cases. The reduction of the neutrophil count methotrexate was associated with a significant below 3000 cells/cm3 can lead to problems improvement in the clinical score compared when giving a bone marrow suppressive agent http://thorax.bmj.com/ with placebo alone. One criticism of this study such as methotrexate. However, monitoring of is the use of a clinical score rather than objec- the white blood count on a regular basis is usu- tive measurements.31 However, most patients ally suYcient to avoid this complication. have a multisystem disease, with many of the Methotrexate can cause mucositis as well as symptoms being subjective. These include nausea and even vomiting.18 34 This is a dose fatigue, myalgias, and pain, and are true symp- dependent eVect, although there is enough toms for the patient, representing indications variation in patient sensitivity that one can see for treatment.
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