Thursday 11 March 2010, 1:58PM
PEARLS No. 227, December 2009, written by Brian R
McAvoy
Clinical question
How effective is methotrexate for maintenance of remission in
Crohn's disease?
Bottom line
Methotrexate (15mg/week) injected intramuscularly for 40 weeks
is an effective treatment (NNT* 4) for preventing relapse among
patients whose disease became inactive while taking higher doses of
intramuscular methotrexate (25mg/week). Side effects occurred in a
small number of patients. These side effects were usually mild in
nature and included nausea and vomiting, cold symptoms, abdominal
pain, headache, joint pain and fatigue. Methotrexate (12.5 to
15mg/week) taken orally was not shown to be an effective treatment
for inactive Crohn's disease.
* NNT = number needed to treat to benefit 1 individual
Caveat
The 3 studies differed significantly with respect to
methodology. Two studies investigated the efficacy of methotrexate
compared to placebo. Two studies looked at methotrexate compared to
6-mercaptopurine, and also investigated oral methotrexate compared
to 5-ASA. One well-designed trial provided evidence that
methotrexate at a dose of 15mg intramuscularly weekly is safe and
effective for maintenance of remission in quiescent Crohn's
disease. The other 2 studies suggested methotrexate is safe, but
failed to show a benefit for lower doses given orally.
Context
Safe and effective long-term treatments that reduce the need for
corticosteroids are required for Crohn's disease. Although purine
antimetabolites (such as azathioprine and 6-mercaptopurine) are
moderately effective for maintenance of remission, patients often
relapse despite treatment with these agents. Methotrexate may
provide a safe and effective alternative to more expensive
maintenance treatment with tumour-necrosis factor-α antagonists
(such as infliximab).
Cochrane Systematic Review
Patel V et al. Methotrexate for maintenance of remission in
Crohn's disease. Cochrane Reviews 2009, Issue 4. Article No.
CD006884. DOI: 10.1002/14651858.CD006884.pub2.
This review contains 3 studies involving 226 participants. PEARLS
No. 227, February 2010, written by Brian R McAvoy.