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Psoriatic arthritis is an auto-immune disease that is often treated with methotrexate (MTX).

In my case, my doctors assure me that MTX is the right medication for this sickness.

However, in the German wikipedia entry on psoriasis, it says that a recent placebo-controlled study couldn't confirm this:

Lange galt, dass MTX besonders gut bei Psoriasisarthritis wirksam ist, allerdings konnte eine in 2012 publizierte randomisierte Placebo-kontrollierte Studie keinen solchen Effekt zeigen.

It cites Reich, The concept of psoriasis as a systemic inflammation: implications for disease management J Eur Acad Dermatol Venereol. 2012 Mar;26 Suppl 2:3-11. doi: 10.1111/j.1468-3083.2011.04410.x

Is that study accepted, valid and/or otherwise trustworthy?

  • To be clear, MTX does treat psoriasis. The claim is, that it's "more efficient" for the psoriatic arthitis than other treatments. – npst Sep 1 '13 at 3:50
  • Who claims that it is more efficient? – user5582 Sep 1 '13 at 6:21
  • @npst: Note that effectiveness, efficacy and efficiency had different but related meanings when referring to medicine. While I know nothing of this drug, your doctor's recommendation may be influenced not merely by efficacy, but side-effects, cost, known allergies, availability, etc. The claim you cite says it is ineffective, so we can research that. You haven't shown there is a notable claim that it is the most anything. – Oddthinking Sep 1 '13 at 7:52
  • @Sancho: The first sentence of the German wikipedia snippet translates to "MTX was long believed to work especially well against Psoriatic Arthritis." – npst Sep 1 '13 at 14:47
  • @npst But "more efficient" than other treatments? – user5582 Sep 1 '13 at 15:40
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Although methotrexate has been used for years now to treat psoriatic arthritis (PsA) with the impression of good effectiveness in both treating physicians, and patients, there has been scant proof of such effectiveness. The latest and most comprehensive data we have is from the 2012 MIPA trial [1]

The MIPA trial was a placebo-controlled study involving 221 methotrexate-naive individuals with PsA enrolled in 22 European centers over a period of 5 years. Initial methotrexate at 7.5 mg per week was increased to 10 mg per week at week 4, and to a target dose of 15 mg per week at week 8. In individuals with persistently active disease, the dose could be adjusted to 20 mg per week at 4 months and 25 mg per week at 5 months. Concomitant NSAIDs were allowed, but not systemic glucocorticoids or other immunomodulatory agents. Response to treatment was assessed at 3 months and 6 months. Of 109 people in the methotrexate arm, only 67 were 'valid compliant completers', compared with 61 of 112 in the placebo arm.

Although intention to treat analyses found significant improvement in physician and patient global assessments, there was no difference between placebo and active treatment in measures such as ESR, CRP, tender and swollen joint counts, and HAQ scores.

There has been some criticism of the trial including that the dose of methotrexate was escalated too slowly, and only 11% of subjects received doses greater than 15 mg per week, whereas 20 - 25 mg per week is more commonly used in the USA.

Nevertheless we lack good evidence currently for the efficacy of methotrexate in PsA, and perhaps patients should be first trialled on Leflunomide for which we do have efficacy data. [2]


[1] Kingsley GH, Kowalczyk A, Taylor H, [..], Scott DL. A randomized placebo-controlled trial of methotrexate in psoriatic arthritis. Rheumatology (Oxford). 2012 Aug;51(8):1368-77. doi: 10.1093/rheumatology/kes001. PubMed PMID: 22344575.

[2] Kaltwasser JP, Nash P, Gladman D, [..], Mease P. Efficacy and safety of leflunomide in the treatment of psoriatic arthritis and psoriasis: a multinational, double-blind, randomized, placebo-controlled clinical trial. Arthritis Rheum. 2004 Jun;50(6):1939-50. doi: 10.1002/art.20253. PubMed PMID: 15188371.

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Methotrexate is used to treat psoriatic arthritis. Several studies have concluded it is effective, thus only the tolerability of the patient should be taken into account when starting methotrexate therapy.

Methotrexate is an effective and safe agent in psoriatic arthritis. In the last decade, methotrexate has emerged as a useful second line agent for a variety of arthritides. However, there still exists some reluctance for its wider use mainly because of concerns about its liver side effects [1].

A study of active psoriatic arthritis found no evidence for MTX improving synovitis and consequently raises questions about its classification as a disease-modifying drug in psoriatic arthritis [2]. However, this is a 6 month study. The others that claim methotrexate is effective gathered data for more than 6 months [3, 5, 6].

Methotrexate can be used early in the course of psoriatic arthritis with good results [3]. When it comes to long term terapy, methotrexate conferred no advantage with respect to clinical response or longterm damage even after 24 months of therapy [4]. Methotrexate is superior to intramuscular gold in the likelihood of achieving a clinical response and in permitting an individual to continue longterm treatment [5]. When compared to cyclosporin A, one study shows that low-dose cyclosporin A and methotrexate are both effective in the treatment of psoriatic arthritis, but the differences in the tolerability of these drugs must be considered at the start of therapy [6].

In psoriasis, the rate of production of epithelial cells in the skin is greatly increased over normal skin. This differential in proliferation rates is the basis for the use of Methotrexate to control the psoriatic process [7].


References:

  1. Espinoza LR, Zakraoui L, Espinoza CG, GutiĂŠrrez F, Jara LJ, Silveira LH, CuĂŠllar ML, MartĂ­nez-Osuna P. Psoriatic arthritis: clinical response and side effects to methotrexate therapy. J. Rheumatol. 1992 Jun;19(6):872-7. PubMed PMID: 1404123.

  2. Kingsley GH, Kowalczyk A, Taylor H, Ibrahim F, Packham JC, McHugh NJ, Mulherin DM, Kitas GD, Chakravarty K, Tom BD, O'Keeffe AG, Maddison PJ, Scott DL. A randomized placebo-controlled trial of methotrexate in psoriatic arthritis. Rheumatology (Oxford). 2012 Aug;51(8):1368-77. doi: 10.1093/rheumatology/kes001. PubMed PMID: 22344575.

  3. Singh YN, Verma KK, Kumar A, Malaviya AN. Methotrexate in psoriatic arthritis. J Assoc Physicians India. 1994 Nov;42(11):860-2. PubMed PMID: 7868484.

  4. Abu-Shakra M, Gladman DD, Thorne JC, Long J, Gough J, Farewell VT. Longterm methotrexate therapy in psoriatic arthritis: clinical and radiological outcome. The Journal of Rheumatology [1995, 22(2):241-245]

  5. Lacaille D, Stein HB, Raboud J, Klinkhoff AV. Longterm therapy of psoriatic arthritis: intramuscular gold or methotrexate? J. Rheumatol. 2000 Aug;27(8):1922-7. PubMed PMID: 10955334.

  6. Spadaro A, Riccieri V, Sili-Scavalli A, Sensi F, Taccari E, Zoppini A. Comparison of cyclosporin A and methotrexate in the treatment of psoriatic arthritis: a one-year prospective study. Clinical and Experimental Rheumatology [1995, 13(5):589-593]

  7. Drugs.com. Methotrexate

  • You say It doesn't improve extra-articular complications of arthritis like synovitis. but synovitis is the hallmark of inflammatory arthritis, and is articular. – HappySpoon Jun 7 '14 at 20:31

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