Original articleMethotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion☆
Introduction
Methotrexate is used by most rheumatologists as the first-line disease-modifying antirheumatic drug for patients with rheumatoid arthritis (RA). This choice rests on the good effectiveness and safety profile of the drug, its low cost, and the availability of long-term follow-up data on RA patients given methotrexate [1], [2]. In addition, recent data indicate that methotrexate can produce substantial survival benefits by reducing cardiovascular mortality in patients with RA [3].
However, 20 years after the first randomized controlled trials (RCTs) demonstrated that methotrexate as monotherapy was effective in decreasing disease activity in RA [4], [5], 15 years after the first RCTs established its ability to slow the progression of structural joint damage [6], [7], and nearly 10 years after the first RCTs of the efficacy and safety of methotrexate combined with other conventional disease-modifying antirheumatic drugs [8], [9] or biotherapies [10], [11], [12], considerable variability continues to exist in the modalities of methotrexate use in RA, most notably regarding starting and maximal dosages, dosage adjustment, criteria used to monitor patients in daily practice, and the use of folate supplementation.
The objective of this work was to develop clinical practice guidelines for the use of methotrexate in patients with RA, using evidence from the international literature and expert opinion, with the goal of optimizing everyday clinical practice [13].
Section snippets
Methods
The procedure for developing the recommendations involved several steps, as detailed in the article by Pham et al. [14], [15].
Results and discussion
Eight recommendations about using methotrexate in patients with RA were developed during the 2005 Meeting of Rheumatology Experts. The wording and strength of the recommendations are shown in Table 1, as well as the extent of agreement of the experts with each recommendation.
Acknowledgments
We are grateful to Catherine Mazzacco, Gérard Goldfarb, and Fabrice Michiels at Abbott France for their support; Janine de Palmas and Fabien Moll-François at Margaux Orange for their help; and the 75 experts who used their knowledge and their experience of rheumatoid arthritis to develop the recommendations [15].
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This project was supported by a grant from Abbott France.