A new study in JAMA Dermatology raises an interesting question for physicians who treat psoriasis patients. Does methotrexate work best in patients with plaque psoriasis alone or patients who have both psoriasis and arthritis?
Currently, most treatment recommendations call for methotrexate as first line therapy in psoriasis (PsO), especially when arthritis is present. But in this study of psoriasis patients with and without psoriasis, researchers found that methotrexate works best in patients with psoriasis, but not both psoriasis and arthritis.
"In this study, methotrexate was well tolerated and effective in treating psoriasis. It was more effective, with fewer adverse effects in patients with psoriasis who did not have psoriatic arthritis (PsA). Therefore, methotrexate can be recommended as first-line treatment for psoriasis without arthritis,” wrote researchers who were led by Jinhua Xu, M.D., Ph.D., of Fudan University in Shanghai.
Psoriasis treatment guidelines by the American Academy of Dermatology recommend treatment with oral traditional systemic agents including methotrexate (also available as an injection), cyclosporine and acitretin. Recommended biologic treatments for PsO include various TNF, IL-12/23, IL-17 and IL-23 inhibitors, but fewer than 10 percent of psoriasis patients receive biologics and in most countries, methotrexate is considered a first-line treatment.
Ultimately, the treatment route depends on the individual needs of the patient, wrote Alan Menter, M.D., and colleagues in the 2011 AAD guidelines published in the Journal of the American Academy of Dermatology.
“Treatment options for psoriasis must be tailored to the individual patient, taking into account efficacy, side effects, availability, ease of administration, comorbidities, family history, and coexisting diseases,” they wrote.
This was a prospective, single-arm, interventional study of 235 patients (mean age 47 years) of whom 107 had psoriasis only and 128 had both psoriasis and psoriatic arthritis. They were treated with a 12-week course of low-dosage oral methotrexate (7.5-15 mg) weekly over the course of two years from April 1, 2015 to Dec. 31, 2017.
After eight weeks, 3.1% of psoriasis patients with psoriatic arthritis experienced a 90% reduction in PASI levels from baseline as compared to 11.2% of patients with psoriasis only. By week 12, 14.8% of PsO/PsA patients achieved PASI90 as compared to 25.2% of patients with PsO only.
Adverse events, which were primarily mild and occurred more often in patients with both PsO and PsA, included dizziness, gastrointestinal symptoms and hepatoxicity.
Kexiang Yan, MD, PhD; Yuanjing Zhang, MD; Ling Han, MD, PhD; et al. "Safety and Efficacy of Methotrexate for Chinese Adults With Psoriasis With and Without Psoriatic Arthritis," JAMA Dermatology. Jan. 30, 2019. DOI:10.1001/jamadermatol.2018.5194
On Wednesday (Feb. 13 2019), the American Academy of Dermatology and the National Psoriasis Foundation released updated treatment guidelines for psoriasis patients treated with biologics and seperate guidelines for managing comorbidities in psoriasis.