Methotrexate Hepatotoxicity and the Impact of Nonalcoholic Fatty Liver Disease

Author’s Accepted Manuscript Methotrexate Hepatotoxicity and the Impact of Nonalcoholic Fatty Liver Disease Shetty Akshay, Cho WonKyung, Alazawi William, Syn Wing-Kin www.elsevier.com

PII: DOI: Reference:

S0002-9629(17)30139-8 http://dx.doi.org/10.1016/j.amjms.2017.03.014 AMJMS410

To appear in: The American Journal of the Medical Sciences Received date: 16 November 2016 Revised date: 10 February 2017 Accepted date: 8 March 2017 Cite this article as: Shetty Akshay, Cho WonKyung, Alazawi William and Syn Wing-Kin, Methotrexate Hepatotoxicity and the Impact of Nonalcoholic Fatty Liver Disease, The American Journal of the Medical Sciences, http://dx.doi.org/10.1016/j.amjms.2017.03.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Methotrexate Hepatotoxicity and the impact of Nonalcoholic Fatty Liver Disease Authors: Shetty Akshay, MD1$, Cho WonKyung, BA1$, Alazawi William, MD PhD3, 4, Syn Wing-Kin, MD1, 2*

Short title: Methotrextate Hepatotoxicity and Fatty Liver Disease

Affiliations: 1. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA 2. Section of Gastroenterology, Ralph H Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA 3. Department of Hepatology, Barts Health NHS Trust, London, United Kingdom 4. Centre for Immunobiology, Blizzard Institute,Queen Mary University of London, London, United Kingdom

$: co-first authorship *Senior and Corresponding Author: Dr. Wing-Kin SYN, Associate Professor of Medicine, Medical University of South Carolina, Strom Thurmond Building, 114 Doughty Street, MSC 702, Room 402, Charleston SC 29425. Tel: 843-792-3267. [email protected]

Key words: chronic liver disease, drug, hepatotoxicity, metabolic, risk factors, nonalcoholic steatohepatitis

1

Abstract Methotrexate (MTX) is commonly used to treat individuals with rheumatological and dermatological disorders. Current American College of Rheumatology (ACR) and American Association of Dermatology (AAD) guidelines identify diabetes and obesity as risk factors for MTX-induced liver injury. Both diabetes and obesity are components of the metabolic syndrome, and are also risk factors for nonalcoholic fatty liver disease (NAFLD). NAFLD affects around 40% of the US population and those with more advanced NAFLD (i.e. nonalcoholic steatohepatitis with or without fibrosis) are likely to develop progressive liver disease. As such, individuals who are treated with MTX may need to be screened for advanced NAFLD, as this may put them at increased risk of MTX-induced liver injury.

In this mini-review, we will review the current ACR and AAD guidelines on MTX hepatotoxicity, discuss the evidence (or lack thereof) on the impact of metabolic risk factors on MTX-induced liver injury, and highlight areas that need further research. Introduction Methotrexate (MTX) is an inhibitor of the enzyme dihydrofolate reductase, and it reduces levels of folate cofactors necessary for nucleic acid synthesis [1]. Initially used to treat childhood leukemia, it has since gained popularity in treatment of various dermatological, rheumatological, oncological, and inflammatory bowel diseases (IBD) [2]. Since its inception into the treatment armamentarium for rheumatoid arthritis (RA) and psoriasis, MTX has continued to be the most favored steroid-sparing immunosuppressant [3]. The introduction of MTX preceded the era of randomized control trials (RCTs); therefore, limited safety data existed prior to initiation of MTX use. However, with continued use of MTX, recognition of its adverse side effects has grown. One important side effect is 2

liver injury, and MTX-associated induced liver injury has been noted to be more prevalent in patients with psoriasis than those with RA. The reasons for this apparent disparity is not known, but there is a much higher prevalence of metabolic syndrome including nonalcoholic fatty liver disease in patients with psoriasis compared to the general population [4-7]. Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease in the US and is strongly associated with metabolic risk factors such as type 2 diabetes mellitus (T2DM) and obesity. It is considered the hepatic manifestation of metabolic syndrome [8] and affects nearly 40% of the US population, mirroring both the obesity and T2DM epidemics [9-11]. NAFLD encompasses a wide spectrum of histopathological states, ranging from simple steatosis (NAFL) to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular cancer [12]. Among patients treated with MTX, those with metabolic syndrome are at increased risk of MTX hepatotoxicity. Nevertheless, it is unclear if these individuals have underlying NAFLD that predisposes them to liver injury. We will review the association between metabolic syndrome and MTX-associated liver injury, discuss the current clinical practice guidelines for monitoring MTX associated liver injury, examine their limitations, and highlight areas for future research. History of Baseline Liver Biopsy MTX hepatotoxicity was first reported in 1955 when five children who achieved remission from acute leukemia after treatment with MTX developed liver cirrhosis [13]. Over the ensuing three decades, despite increasing recognition of MTX-associated liver injury, which includes hepatic steatosis followed by hepatic fibrosis and, rarely, cirrhosis [14], the underlying mechanism for hepatotoxicity remains poorly understood. As such, MTX-associated liver injury continued to be the primary concern for both patients and 3

prescribers of long-term MTX, with guidelines recommending monitoring for MTXassociated hepatotoxicity going as far back as 1972 [15]. The early series of guidelines published by the American Association of Dermatology (AAD) for MTX monitoring in patients with psoriasis (i.e. 1972, 1973, 1982, 1988) all recommended pre-treatment or baseline liver biopsy followed by serial biopsies; these were initially based on treatment duration but later modified to account for increasing cumulative doses [3, 15, 16]. Questions regarding the need and utility of serial biopsies was raised by multiple authors [17-20], as significant variability was noted in reports of hepatotoxicity detected among patients treated with MTX, ranging from minimal change in liver histology to advanced fibrosis (up to 33%) and cirrhosis (up to 26%) [15, 17, 19, 2125]. Adjustment for cumulative dosing as well as risk factors such as alcohol, obesity, and T2DM improved our understanding of which group of patients was at higher risk of MTXassociated liver injury. Therefore, in the 1998 guidelines, the AAD removed the need for baseline biopsies in patients without risk factors for MTX-associated liver injury [3]. The 1994 guidelines published by the American College of Rheumatology (ACR) also discouraged baseline liver biopsies [26]. Evidence Behind Current Clinical Guidelines MTX Monitoring in Psoriasis Histological assessment of liver biopsies in numerous studies [17, 19, 21-25] lacked conformity in using an established histological scale [18, 27]. The Roenigk scale (Table 1), which was previously advocated by the AAD, or an ad-hoc scale (described in the study itself) were used for histologic assessment of MTX-associated liver toxicity in these studies, but neither Roenigk nor the described scales were ever validated for evaluation in any other liver disease. Comparison of the Roenigk scale to established grading scores such 4

as the Ishak and Scheuer scoring system (Tables 2 and 3) in 2004 by Aithal et al demonstrated that the Roenigk scale overestimated the degree of fibrosis by classifying patients with minimal fibrosis as advanced fibrosis [28]. In low-risk psoriasis patients, this study by Aithal et al served as the basis for the current AAD guideline from 2009 for consideration of a liver biopsy after a total cumulative MTX dose of 3500 - 4000mg, or alternatively, discontinuing therapy. In all seven studies [17, 19, 21-25], apart from the absence of an established scoring system, lack of assessment of risk factors, such as obesity and T2DM, likely also contributed to the discrepancy in degree of fibrosis with MTX use. In 2007, Rosenberg et al showed that when risk factors such as obesity, T2DM, alcohol use, or viral hepatitis were controlled among psoriasis patients, 38% of patients with risk factors on weekly MTX dosing developed severe fibrosis at a cumulative dose of 1600 mg, whereas only 9% of patients without risk factors developed severe fibrosis [29]. The study assessed liver histology using the grading scale described in Kleiner et al (Table 4), the scoring system established and validated by the pathology committee of the NASH clinical research network [30]. Overall, multiple studies [20, 28, 29, 31] suggested higher risk of advanced fibrosis in psoriasis patients with risk factors such as obesity, T2DM, alcohol use, or underlying liver disease. As such, the current AAD guidelines from 2009 recommended consideration of alternative therapy in patients with risk factors for MTX-associated liver injury, and if MTX use is pursued, consideration for liver biopsy for staging during initiation of MTX treatment followed by serial biopsies every 1000 to 1500 mg of cumulative MTX dose [32].

5

MTX Monitoring in Rheumatoid Arthritis A 1989 prospective study of 29 patients with RA on long-term, low-dose, weekly MTX followed for 4 years showed good correlation of liver enzymes (LE) with histological changes on liver biopsy, namely fibrosis, from MTX use, and this served as the platform for the 1994 guidelines published by the ACR regarding MTX monitoring for hepatotoxicity [33]. The correlation of LE to histological changes in MTX-associated liver injury was further corroborated by another prospective study in 1996 of 3 separate cohorts of 94 patients with RA on long-term, low-dose, weekly MTX followed for 5 years [34]. Both of the above studies however, did not report co-morbidities, such as T2DM or obesity, but discussed alcohol as a risk factor for MTX-associated liver injury. Unlike psoriasis, patients with RA appear to harbor a lower risk for MTX-associated hepatotoxicity, specifically hepatic fibrosis. A meta-analysis of 15 studies on sequential liver biopsies in 1991 showed that the risk of advanced fibrosis by Roenigk scale (grade IIIB or IV) in RA patients was significantly lower than psoriasis patients (2.7% vs 7.7%); however, many studies in this meta-analysis did not report baseline liver biopsies and insufficiently reported risk factors associated to MTX-associated liver injury [35, 36]. In a review of 27 prospective studies, following a total of 3808 patients with RA on low-dose MTX (mean 10.5mg/week) for approximately 4.6 years, Salliot et al reported a pooled result of 12.9% patients who developed LE elevations twice the upper limit of normal (ULN), and a total of 3.7% patients who had to stop MTX treatment [36]. A separate review by Visser et al of 18 studies (7 overlapping with Salliot) with 2199 RA patients on low-dose MTX (mean 12.5mg/week) followed for about 3.5 years reported a pooled result showing 17% of patients developed LE elevations greater than twice the ULN. Though the validity of the above analysis is limited due to the heterogeneity among studies and underreporting of risk factors such as 6

obesity and T2DM, the overall findings suggest a lower prevalence of hepatotoxicity from MTX use in RA patients compared to psoriasis patients. We hypothesize that this is likely related to the lower prevalence of metabolic syndrome and/or NAFLD in RA patients. The most recent ACR guidelines from 2009 recommend repeating LE every 4 to 6 weeks when initiating MTX treatment or changing dosage. Once a stable dose is achieved, LE should be checked every 4 to 12 weeks; if LEs are elevated more than three times the ULN, MTX therapy should be stopped, and if LEs are persistently abnormal then further diagnostic testing is recommended [37]. NAFLD/NASH and Association with MTX Metabolic Syndrome Risk factors associated with NAFLD include obesity, T2DM, hyperlipidemia (HLD), hypertension, obstructive sleep apnea, polycystic ovarian syndrome, and gout, all of which constitute the metabolic syndrome and are summarized further in Table 5 [12, 38-40]. The apparent disparity between MTX-associated hepatotoxicity, specifically fibrosis, in psoriasis and RA patients is likely related to differences in the prevalence of metabolic risk factors. Cross-sectional studies investigating the prevalence of metabolic syndrome among RA patients are equivocal, with one study [41] revealing an odds ratio (OR) of 1.87, while two other studies showing no significant difference compared to the control population [42, 43]. By contrast, psoriasis is associated with a higher prevalence of metabolic syndrome, with OR ranging from 1.65 to 5.29 in four cross-sectional studies, when compared to the control population [4-7]. Prevalence of NAFLD is also higher in psoriatic patients. In a recent meta-analysis, which reviewed seven case-controlled studies, psoriatic patients compared to patients without psoriasis had an OR of 2.15 for NAFLD, diagnosed via imaging [44]. Studies linking metabolic risk factors to MTX-associated liver 7

injury are summarized in Table 6. An international cooperative study completed in 1973 to study liver damage from MTX use for psoriasis was the first to identify obesity and T2DM as risk factors for MTX associated liver injury [45]. More recent retrospective studies among psoriasis patients have continued to support this, showing a dramatic increase in the risk of fibrosis from 9% to 38% when comparing patients without risk factors to those with obesity or T2DM on MTX therapy [20, 29, 31]. Obesity and HLD were identified as risk factors for permanent discontinuation of MTX therapy among RA patients due to elevated LE [46]. End-stage MTX-associated liver disease requiring liver transplantation was reviewed by Dawwas and Aithal by analyzing the Organ Procurement and Transplantation Network data from 1987 to 2011 [47]. End-stage MTX-associated liver disease requiring liver transplantation was rare (0.07%), and their risk factor profile when compared to other liver diseases was similar to that of NAFLD/NASH patients requiring liver transplantation, suggesting that this group of patients may have had undiagnosed NAFLD/NASH that placed them at higher risk for progressive fibrosis and cirrhosis. The association between MTX-associated liver injury and the presence of metabolic risk factors suggests that these patients could potentially have underlying undiagnosed NAFLD/NASH, the hepatic component of the metabolic syndrome. Abnormal Liver Enzymes in NAFLD In psoriasis patients who developed MTX-associated liver injury, LE underestimated the degree of fibrosis on histologic assessment, with patients with advanced fibrosis and cirrhosis showing no significant abnormalities in LE, and alternatively patients with significantly elevated LE showing minimal histological changes on liver biopsy [48, 49]. The utility of LE to screen for NAFLD and to differentiate it from NASH with fibrosis is poor, 8

as LE are often normal in patients with liver fibrosis, and conversely, those with abnormal LE may only have non-specific changes on liver biopsy [50]. The limitations of using LE in NAFLD was further highlighted by Fracanzani et al who evaluated patients with biopsyproven fatty liver disease and found that in patients with a normal ALT, 59% had evidence of NASH on liver biopsies [51]. Mofrad et al compared NAFLD patients with a normal alanine transaminase (ALT) to those with an elevated ALT and found that the prevalence of advanced fibrosis in both groups was similar [52]. As such, normal LE does not exclude the possibility of advanced NAFLD, while elevated LE do not imply that the individual has advanced disease. These findings support the need for histological assessment of the liver in patients with NAFLD who are being treated with rising cumulative doses of MTX. Liver Histology and the Importance of Steatohepatitis and Fibrosis In the first comparison of the Roenigk scale to validated scales like the Ishak and Scheuer grading scales, Aithal et al [28] highlighted that the Roenigk scale takes steatosis and steatohepatitis into account (Table 1), but their presence or absence does not factor in to clinical decision making with MTX-associated liver injury [3, 16, 28, 31]. In a metaanalysis of 11 longitudinal cohort studies of paired liver biopsies, NAFLD patients were assessed for fibrosis progression rate; it estimated that patients with NAFL progressed by a stage of fibrosis on Brunt classification in 14.3 years, compared to 7.1 years for patients with NASH [53]. While these observational studies come with their limitations, a conservative conclusion would be that both NAFL and NASH carry a risk of progressive fibrosis. As such, patients graded by a Roenigk scale as grade I or II on baseline biopsies with metabolic features could very well have been classified as NAFL/NASH and potentially carried a higher risk of progressive fibrosis on MTX therapy.

9

Animal Studies with MTX-associated Liver Injury The methionine-choline deficient (MCD) diet has been shown to induce steatohepatitis with fibrosis in mice, which resembles NASH in humans [54]. Hardwick et al studied wild type mice fed either a normal diet or the MCD diet for 8 weeks. Mice were then administered a single dose of MTX, at varying concentrations (0, 20, 40, or 100 mg/kg). No detectable fibrosis was seen after MTX treatment in mice fed with the normal diet. In contrast, MCD diet fed mice sustained severe liver injury, and developed fibrosis and biliary hyperplasia. Importantly, the amount of fibrosis was dose-responsive, with mice that received 100 mg/kg of MTX displaying more pronounced bridging fibrosis [55]. Kyriakides et all performed a similar experiment, where wild type mice were fed either a normal diet or the MCD diet for 8 weeks, followed by a one time administration of 0, 10, 40, or 100mg/kg MTX. MCD diet-fed mice sustained significant fibrosis, compared to no fibrosis in mice that were fed the control diet [56]. These studies in aggregate support the hypothesis that NASH (with or without fibrosis) increases the risk for MTX-induced progressive fibrosis. Human Studies Evaluating NAFLD and MTX-associated Liver Injury Two retrospective studies have since evaluated MTX-associated liver injury in psoriasis patients using the Brunt NASH score. Langman et al reviewed 24 patients with psoriasis on weekly low dose MTX who had undergone liver biopsies [57]. They compared the liver biopsies graded with the Roenigk classification to the NASH grading scale developed by Brunt et al in 1999 [58]. At a cumulative dose of approximately 5000 mg, 17 out of the 24 patients developed NASH-like injury pattern, and 13 out of those 17 had risk factors for NAFLD such as obesity or diabetes. Progression of steatohepatitis or fibrosis also positively correlated with these risk factors when the histological assessment was 10

completed using the Brunt grading scale, but no correlation was noted when histological assessment was completed with the Roenigk classification [57]. In 2007, Rosenberg et al studied the degree of steatohepatitis among 71 psoriasis patients who developed MTXassociated hepatotoxicity on low-dose weekly MTX by using the Kleiner NAFLD activity score (Table 4) [29, 30]. The study showed that 38.5% of patients with risk factors, which included obesity, T2DM, alcohol use, and viral hepatitis, developed steatohepatitis (NAFLD activity score ≥5) from a median cumulative dose of 1500mg, compared to only 11% of patients without risk factors who developed steatohepatitis at a higher cumulative dose of 2200mg [29]. A limitation in both these studies was the lack of baseline liver biopsies to compare the change or progression from either steatosis or steatohepatitis to a combination of steatohepatitis with or without fibrosis. Other Risk Factors for MTX-associated Liver Injury (Table 7) Alcohol Excess alcohol consumption is a well-established risk factor for both alcohol-related liver injury and MTX-associated livery injury, with the quantity of alcohol consumed being a major predictor. In a meta-analysis by the Whiting-O’Keefe group, heavy alcohol consumption (>100gm/week) was associated with an increased risk of developing MTXassociated liver fibrosis, up to 5 times higher, and this risk is observed even with lower doses of MTX therapy [28, 29, 35]. Although there is no consensus regarding the amount of alcohol that poses a risk, drinking greater than 20g of alcohol per day is generally considered excessive, and alternative treatment modalities should be considered in these patients who consume this amount.

11

Treatment Regimens Higher dosing frequency and cumulative dosing are associated with hepatic fibrosis. Daily, every other day, or three divided doses weekly are almost never used in the current treatment for psoriasis, RA, or IBD, as these dosing frequencies can increase the risk of hepatic fibrosis by up to 4-fold [59-61]. By contrast, long-term, low-dose (<20mg), onceweekly regimens for psoriasis patients with no other risk factors have not been associated with development of advanced hepatic fibrosis [17, 28]. Aithal et al noted that the risk of hepatic fibrosis increased from 0% to 2.6% when the cumulative dose increased from 1,500 mg to 4,500 mg, and this risk increased further to 8.2% when cumulative doses exceeded 5,000 mg. It was also noted that the cumulative amount of MTX did not correlate with the severity of liver fibrosis as assessed by the Ishak score [28]. Miscellaneous Underlying chronic liver disease, regardless of etiology (e.g. viral hepatitis B or C, alcoholic liver disease, genetic liver diseases, or toxin/drug-associated liver diseases), is well recognized to increase the risk of MTX-associated hepatic fibrosis [32, 37]. Genetic predisposition has also been studied, though its clinical significance as a risk factor for hepatotoxicity remains unclear. A meta-analysis studying the methylenetetrahydrofolate reductase (MTHFR) single nucleotide polymorphism in RA patients treated with MTX showed that the C677T polymorphism was associated with an increased risk of overall liver toxicity; however, the study considered mildly abnormal liver enzymes (LE) (i.e. < 3 times the ULN) to be of similar significance with LE elevations that were greater than 3 times the ULN [62].

12

Protective Factor: Folate Supplementation Since MTX decreases folate cofactors necessary for nucleic acid synthesis, folic and folinic acid supplementation has been studied to decrease the risks associated with MTX use. Two independent meta-analyses showed that low dose (1mg/day) folic or folinic acid supplementation reduced the absolute risk of LE elevations from MTX use in RA patients [63, 64]. Limited studies, however, exist for treatment in psoriasis [65], and two RCTs – one double blind placebo controlled and one open label – showed no improvements in serum LEs despite daily folic acid supplementation (5mg/day) [66] [67].

Recommendations (Figure 1) Evaluation of a patient at risk for hepatotoxicity from MTX should therefore, include assessment for risk factors for metabolic syndrome, as listed in Table 5, and the above discussed MTX-associated liver injury risk factors, summarized in Table 7. The risk of hepatotoxicity in long-term use of low-dose MTX dosed weekly is low in patients without risk factors. The risk of MTX-associated liver injury increases when the cumulative dose exceeds 4000mg. In this patient population, it is reasonable to monitor LE as recommended by ACR when therapy is being initiated. Once the cumulative dose of MTX exceeds 4000mg, an assessment of fibrosis should be made in consultation with a hepatologist, following which a decision can be made regarding continued versus discontinuing therapy. All patients being treated with MTX should be supplemented with folic acid.

13

Patients with risk factors should be counselled on the risks and benefits of MTX use, and consideration should be given to alternative therapies. Individuals who are being considered for MTX treatment despite harboring risk factors should be evaluated by a hepatologist prior to treatment, and possibly during the duration of treatment. The frequency or intensity of monitoring required is dependent on the individual’s risk factors. For those with the metabolic syndrome or NAFLD, it is important to differentiate NAFL from NASH (with or without fibrosis), as it is likely that those with NASH, and particularly those with NASH-fibrosis, will be at a higher risk for MTX-associated hepatotoxicity. As the sensitivity of LE in distinguishing NAFL from NASH (+/- fibrosis) is poor, and LE is a poor predictor of MTX-associated liver injury, the liver biopsy remains the gold standard in identifying those with NASH and for staging MTX-associated liver injury. However, as a liver biopsy is invasive and it would be impractical to perform a liver biopsy for all individuals with metabolic risk factors, we recommend using non-invasive fibrosis panels (e.g. FibroSure, Fibrotest, NAFLD fibrosis score, FIB-4) or methods such as liver stiffness measurements (e.g. transient elastrography) to assess fibrosis risk. If there is concern for fibrosis, a liver biopsy should then be performed. If the likelihood of fibrosis is low, and a decision is made to initiate therapy, repeat fibrosis evaluation should be undertaken after every 2000mg (with either LSM and/or a liver biopsy) (summarized in Figure 1). Future Research The metabolic syndrome comprises a constellation of medical disorders and pathophysiological states, ranging from central obesity and insulin resistance to nocturnal hypoxia and disruption of the circadian clock. We have highlighted the association of obesity, T2DM, HLD, and NAFLD to MTX-associated liver injury, but the impact of other metabolic risk factors (described in Table 5) on MTX-associated liver injury is unknown, 14

and needs to be better understood. Importantly, whether NAFL, NASH, or fibrosis alone (or in combination) are risks factors for MTX-associated liver injury in humans remains unclear, and will need to be better studied in prospective studies. Specifically, it will be necessary to understand if liver fibrosis is a direct result of MTX or underlying NAFL/NASH, or both. The development of non-invasive serologic markers for steatohepatitis and fibrosis offers a potential alternative to the liver biopsy, but these need to be further validated in prospective studies. Improving imaging modalities for assessing fibrosis (such as the elastrography techniques) are additional alternatives. As such, future studies should include the use of these non-invasive tools which would hopefully allow us to monitor patients regularly without the need for a liver biopsy. References

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Bertino JR. THE MECHANISM OF ACTION OF THE FOLATE ANTAGONISTS IN MAN. Cancer research. 1963;23:1286-1306. Jolivet J, Cowan KH, Curt GA, et al. The pharmacology and clinical use of methotrexate. The New England journal of medicine. 1983;309(18):1094-1104. Roenigk HH, Jr., Auerbach R, Maibach H, et al. Methotrexate in psoriasis: consensus conference. Journal of the American Academy of Dermatology. 1998;38(3):478-485. Gisondi P, Tessari G, Conti A, et al. Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case-control study. The British journal of dermatology. 2007;157(1):68-73. Koku Aksu AE, Saracoglu ZN, Metintas S, et al. Age and gender differences in Framingham risk score and metabolic syndrome in psoriasis patients: A crosssectional study in the Turkish population. Anatolian journal of cardiology. 2016. Langan SM, Seminara NM, Shin DB, et al. Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom. The Journal of investigative dermatology. 2012;132(3 Pt 1):556-562. Sommer DM, Jenisch S, Suchan M, et al. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Archives of dermatological research. 2006;298(7):321-328. Williams T. Metabolic Syndrome: Nonalcoholic Fatty Liver Disease. FP essentials. 2015;435:24-29. Armstrong MJ, Adams LA, Canbay A, et al. Extrahepatic complications of nonalcoholic fatty liver disease. Hepatology (Baltimore, Md.). 2014;59(3):1174-1197. Matteoni CA, Younossi ZM, Gramlich T, et al. Nonalcoholic fatty liver disease: a 15

11.

12. 13. 14. 15. 16. 17. 18. 19.

20.

21. 22. 23. 24. 25.

spectrum of clinical and pathological severity. Gastroenterology. 1999;116(6):14131419. Williams CD, Stengel J, Asike MI, et al. Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: a prospective study. Gastroenterology. 2011;140(1):124-131. Angulo P. Nonalcoholic fatty liver disease. The New England journal of medicine. 2002;346(16):1221-1231. Colsky J, Greenspan EM, Warren TN. Hepatic fibrosis in children with acute leukemia after therapy with folic acid antagonists. A.M.A. archives of pathology. 1955;59(2):198-206. Taylor WJ, Korendowych E, Nash P, et al. Drug use and toxicity in psoriatic disease: focus on methotrexate. The Journal of rheumatology. 2008;35(7):14541457. Roenigk HH, Jr., Maibach HI, Weinstein GD. Use of methotrexate in psoriasis. Archives of dermatology. 1972;105(3):363-365. Roenigk HH, Jr., Auerbach R, Maibach HI, et al. Methotrexate in psoriasis: revised guidelines. Journal of the American Academy of Dermatology. 1988;19(1 Pt 1):145-156. Boffa MJ, Chalmers RJ, Haboubi NY, et al. Sequential liver biopsies during longterm methotrexate treatment for psoriasis: a reappraisal. The British journal of dermatology. 1995;133(5):774-778. Hassan W. Methotrexate and liver toxicity: role of surveillance liver biopsy. Conflict between guidelines for rheumatologists and dermatologists. Annals of the rheumatic diseases. 1996;55(5):273-275. Kremer JM, Kaye GI, Kaye NW, et al. Light and electron microscopic analysis of sequential liver biopsy samples from rheumatoid arthritis patients receiving longterm methotrexate therapy. Followup over long treatment intervals and correlation with clinical and laboratory variables. Arthritis and rheumatism. 1995;38(9):11941203. Malatjalian DA, Ross JB, Williams CN, et al. Methotrexate hepatotoxicity in psoriatics: report of 104 patients from Nova Scotia, with analysis of risks from obesity, diabetes and alcohol consumption during long term follow-up. Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 1996;10(6):369-375. Themido R, Loureiro M, Pecegueiro M, et al. Methotrexate hepatotoxicity in psoriatic patients submitted to long-term therapy. Acta dermato-venereologica. 1992;72(5):361-364. Zachariae H, Kragballe K, Sogaard H. Methotrexate induced liver cirrhosis. Studies including serial liver biopsies during continued treatment. The British journal of dermatology. 1980;102(4):407-412. Tishler M, Caspi D, Halperin Z, et al. A prospective analysis of liver biopsies in rheumatoid arthritis patients receiving long term methotrexate therapy. Rheumatology international. 1992;12(1):39-41. Zachariae H, Sogaard H, Heickendorff L. Methotrexate-induced liver cirrhosis. Clinical, histological and serological studies--a further 10-year follow-up. Dermatology (Basel, Switzerland). 1996;192(4):343-346. Robinson JK, Baughman RD, Auerbach R, et al. Methotrexate hepatotoxicity in 16

26. 27. 28. 29. 30. 31. 32. 33. 34.

35. 36. 37.

38. 39. 40.

psoriasis. Consideration of liver biopsies at regular intervals. Archives of dermatology. 1980;116(4):413-415. Kremer JM, Alarcon GS, Lightfoot RW, Jr., et al. Methotrexate for rheumatoid arthritis. Suggested guidelines for monitoring liver toxicity. American College of Rheumatology. Arthritis and rheumatism. 1994;37(3):316-328. Thomas JA, Aithal GP. Monitoring liver function during methotrexate therapy for psoriasis: are routine biopsies really necessary? American journal of clinical dermatology. 2005;6(6):357-363. Aithal GP, Haugk B, Das S, et al. Monitoring methotrexate-induced hepatic fibrosis in patients with psoriasis: are serial liver biopsies justified? Alimentary pharmacology & therapeutics. 2004;19(4):391-399. Rosenberg P, Urwitz H, Johannesson A, et al. Psoriasis patients with diabetes type 2 are at high risk of developing liver fibrosis during methotrexate treatment. Journal of hepatology. 2007;46(6):1111-1118. Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology (Baltimore, Md.). 2005;41(6):1313-1321. Berends MA, Snoek J, de Jong EM, et al. Liver injury in long-term methotrexate treatment in psoriasis is relatively infrequent. Alimentary pharmacology & therapeutics. 2006;24(5):805-811. Kalb RE, Strober B, Weinstein G, et al. Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference. Journal of the American Academy of Dermatology. 2009;60(5):824-837. Kremer JM, Lee RG, Tolman KG. Liver histology in rheumatoid arthritis patients receiving long-term methotrexate therapy. A prospective study with baseline and sequential biopsy samples. Arthritis and rheumatism. 1989;32(2):121-127. Kremer JM, Furst DE, Weinblatt ME, et al. Significant changes in serum AST across hepatic histological biopsy grades: prospective analysis of 3 cohorts receiving methotrexate therapy for rheumatoid arthritis. The Journal of rheumatology. 1996;23(3):459-461. Whiting-O'Keefe QE, Fye KH, Sack KD. Methotrexate and histologic hepatic abnormalities: a meta-analysis. The American journal of medicine. 1991;90(6):711716. Salliot C, van der Heijde D. Long-term safety of methotrexate monotherapy in patients with rheumatoid arthritis: a systematic literature research. Annals of the rheumatic diseases. 2009;68(7):1100-1104. Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Annals of the rheumatic diseases. 2009;68(7):1086-1093. Ahmed MH, Byrne CD. Obstructive sleep apnea syndrome and fatty liver: association or causal link? World journal of gastroenterology. 2010;16(34):42434252. Li Y, Xu C, Yu C, et al. Association of serum uric acid level with non-alcoholic fatty liver disease: a cross-sectional study. Journal of hepatology. 2009;50(5):1029-1034. Setji TL, Holland ND, Sanders LL, et al. Nonalcoholic steatohepatitis and nonalcoholic Fatty liver disease in young women with polycystic ovary syndrome. 17

41. 42. 43. 44.

45. 46. 47. 48. 49. 50. 51. 52. 53.

54. 55. 56. 57.

The Journal of clinical endocrinology and metabolism. 2006;91(5):1741-1747. da Cunha VR, Brenol CV, Brenol JC, et al. Metabolic syndrome prevalence is increased in rheumatoid arthritis patients and is associated with disease activity. Scandinavian journal of rheumatology. 2012;41(3):186-191. Bilecik NA, Tuna S, Samanci N, et al. Prevalence of metabolic syndrome in women with rheumatoid arthritis and effective factors. International journal of clinical and experimental medicine. 2014;7(8):2258-2265. Ozmen M, Yersal O, Ozturk S, et al. Prevalence of the metabolic syndrome in rheumatoid arthritis. European journal of rheumatology. 2014;1(1):1-4. Candia R, Ruiz A, Torres-Robles R, et al. Risk of non-alcoholic fatty liver disease in patients with psoriasis: a systematic review and meta-analysis. Journal of the European Academy of Dermatology and Venereology : JEADV. 2015;29(4):656662. G. Weinstein, H. Maibach, J. Cosmides, et al. Psoriasis-liver-methotrexate interactions. Archives of dermatology. 1973;108(1):36-42. Kent PD, Luthra HS, Michet C, Jr. Risk factors for methotrexate-induced abnormal laboratory monitoring results in patients with rheumatoid arthritis. The Journal of rheumatology. 2004;31(9):1727-1731. Dawwas MF, Aithal GP. End-stage methotrexate-related liver disease is rare and associated with features of the metabolic syndrome. Alimentary pharmacology & therapeutics. 2014;40(8):938-948. Muller SA, Farrow GM, Martalock DL. Cirrhosis caused by methotrexate in the treatment of psoriasis. Archives of dermatology. 1969;100(5):523-530. Zachariae H, Schiodt T. Liver biopsy in methotrexate treatment. Acta dermatovenereologica. 1971;51(3):215-220. Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Seminars in liver disease. 2008;28(4):386-395. Fracanzani AL, Valenti L, Bugianesi E, et al. Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: a role for insulin resistance and diabetes. Hepatology (Baltimore, Md.). 2008;48(3):792-798. Mofrad P, Contos MJ, Haque M, et al. Clinical and histologic spectrum of nonalcoholic fatty liver disease associated with normal ALT values. Hepatology (Baltimore, Md.). 2003;37(6):1286-1292. Singh S, Allen AM, Wang Z, et al. Fibrosis progression in nonalcoholic fatty liver vs nonalcoholic steatohepatitis: a systematic review and meta-analysis of pairedbiopsy studies. Clinical gastroenterology and hepatology 2015;13(4):643-654.e641649; quiz e639-640. Koteish A, Mae Diehl A. Animal models of steatohepatitis. Best practice & research. Clinical gastroenterology. 2002;16(5):679-690. Hardwick RN, Clarke JD, Lake AD, et al. Increased susceptibility to methotrexateinduced toxicity in nonalcoholic steatohepatitis. Toxicological sciences 2014;142(1):45-55. Kyriakides M, Hardwick RN, Jin Z, et al. Systems level metabolic phenotype of methotrexate administration in the context of non-alcoholic steatohepatitis in the rat. Toxicological sciences2014;142(1):105-116. Langman G, Hall PM, Todd G. Role of non-alcoholic steatohepatitis in methotrexate-induced liver injury. Journal of gastroenterology and hepatology. 2001;16(12):1395-1401. 18

58. 59. 60. 61. 62. 63. 64. 65. 66. 67.

Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. The American journal of gastroenterology. 1999;94(9):2467-2474. Millward-Sadler GH, Ryan TJ. Methotrexate induced liver disease in psoriasis. The British journal of dermatology. 1974;90(6):661-667. Podurgiel BJ, McGill DB, Ludwig J, et al. Liver injury associated with methotrexate therapy for psoriasis. Mayo Clinic proceedings. 1973;48(11):787-792. Zanolli MD, Sherertz EF, Hedberg AE. Methotrexate: anti-inflammatory or antiproliferative? Journal of the American Academy of Dermatology. 1990;22(3):523-524. Fisher MC, Cronstein BN. Metaanalysis of methylenetetrahydrofolate reductase (MTHFR) polymorphisms affecting methotrexate toxicity. The Journal of rheumatology. 2009;36(3):539-545. Prey S, Paul C. Effect of folic or folinic acid supplementation on methotrexateassociated safety and efficacy in inflammatory disease: a systematic review. The British journal of dermatology. 2009;160(3):622-628. Shea B, Swinden MV, Ghogomu ET, et al. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. The Journal of rheumatology. 2014;41(6):1049-1060. Baran W, Batycka-Baran A, Zychowska M, et al. Folate supplementation reduces the side effects of methotrexate therapy for psoriasis. Expert opinion on drug safety. 2014;13(8):1015-1021. Salim A, Tan E, Ilchyshyn A, et al. Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial. The British journal of dermatology. 2006;154(6):1169-1174. Chladek J, Simkova M, Vaneckova J, et al. The effect of folic acid supplementation on the pharmacokinetics and pharmacodynamics of oral methotrexate during the remission-induction period of treatment for moderate-tosevere plaque psoriasis. European journal of clinical pharmacology. 2008;64(4):347-355.

Figure 1: Proposed Algorithm for Evaluation and Monitoring of Methotrexate Hepatotoxicity: Impact of NAFLD

Individuals considered for MTX therapy should be evaluated for possible risk factors as described in Table 7. (A) If there are no obvious risk factors, MTX can be initiated. The risk of hepatotoxicity in long-term use of low-dose MTX dosed weekly is low in patients without risk factors. In this patient population, LE can be used to monitor, as recommended by ACR. Once the cumulative dose of MTX exceeds 4000mg, an assessment of fibrosis should be made in consultation with a Hepatologist. Evaluation would generally involve a liver biopsy and/or liver stiffness measurement (using transient elastrography), following 19

which a decision can be made regarding continued versus discontinuing therapy. (B-C) Individuals with risk factors should be referred to Hepatology. (B) Those with NAFLD or metabolic risk factors should be evaluated for the likelihood / presence of fibrosis. Tests include non-invasive blood markers or liver stiffness measurements. If these demonstrate the presence or a high risk for fibrosis, a liver biopsy should be performed prior to therapy. MTX should be avoided if fibrosis is confirmed. Conversely, those with no evidence (or low likelihood) of liver fibrosis can be treated with MTX, but should undergo regular monitoring as described in (A). (C) Individuals with chronic liver diseases (apart from NAFLD) should also avoid MTX. However, if MTX is to be administered, we recommend evaluation for liver fibrosis as described in (B).

Table 1. Roenigk Classification System [16] Roenigk Fatty Change Nuclear Pleomorphism Grade

Necroinflammation

Fibrosis None

1

None or mild

None or mild

2

Moderate or severe

Moderate or severe

3a

With or without

With or without

With or without mild portal inflammation Moderate or severe portal inflammation With or without

3b 4

With or without With or without

With or without With or without

With or without With or without

None Mild (fibrosis extending into acini Moderate or severe Cirrhosis

Table 2. Ishak scoring system [28] Score Degree of fibrosis 0 1 2 3 4 5 6

No Fibrosis Fibrous expansion of some portal areas +/- short fibrous septa Fibrous expansion of most portal areas +/- short fibrous septa Fibrous expansion of most portal areas with occasional portal to portal bridging Fibrous expansion of portal areas with marked portal to portal and portal to central bridging Marked briding fibrosis with occasional nodule (incomplete cirrhosis) Cirrhosis

Table 3. Scheuer scoring system [28] Score Degree of fibrosis 0 1 2 3 4

No Fibrosis Enlarged, fibrotic portal tracts Periportal or portal to portal septa but intact architecture Fibrosis with architectural distortion but no obvious cirrhosis Probable of definite cirrhosis

20

Table 4. NASH clinical research Network scoring system[30] Steatosis Grade (% parenchyma) Location Microvesicular steatosis 0 1 2 3

<5% 5-35% >33-66% >66%

0 1 2 3

Zone 3 Zone 1 Azonal Panacinar

0 1 -

Not present Present -

Fibrosis 0 1A 1B 1C 2 3 4

None Mild, zone 3, perisinusoidal Moderate, zone 3, perisinusoidal Portal/periportal Perisinusoidal and portal/periportal Bridging fibrosis Cirrhosis

Inflammation Portal Microgranulomas inflammation

Lobular inflammation 0

No Foci

0

1

<2 foci per 200x field

1

2 3

2-4 foci >4 foci

None to minimal Greater than minimal

0

Absent

0

Absent

1

Present

1

Present

Liver cell injury Acidophil bodies Pigmented macrophages

Ballooning 0

None

0

1 2

Few balloon cells Many cells/prominent ballooning

1

None to rare Many

Large Lipogranulomas

0 1

None to rare Many

Megamitochondria 0 1

None to rare Many

Other findings Mallory’s Hyaline 0 1

None to rare Many

Glycogenated nuclei 0 1

None to rare Many

Table 5. Risk factors associated with NAFLD Obesity (central obesity) Diabetes Mellitus type 2 (Insulin resistance) Hypertension Hyperlipidemia Obstructive Sleep Apnea (nocturnal hypoxia) Polycystic Ovarian Syndrome Gout Disruption of circadian rhythm (prolonged night shift work)

21

Table 6: Studies identifying metabolic risk factors for MTX-associated liver injury Author, year

Study design

Study populati on

Country

Cumulat ive dose MTX (mg)

N

Histolo gy Scale

Compar ed pre and post MTX liver biopsy

Durati on of follow up (years )

Control for metab olic risk factors

Clinical variables considered for adjustment

Clinical assessment

Malatjali an et al 1996 [20]

Retrospect ive, hospital based

Psorias is

Canada

Not specifie d

10 4

Roeni gk

Yes

3.8

DM & obesity

Age, gender, cumulative dose, duration of therapy, and alcohol consumptio n

There is an increased risk of severe liver injury in diabetic patients on MTX therapy.

Langma n et al, 2001 [57]

Retrospect ive, hospital based

Psorias is

South Africa

378 – 22,750

24

Roeni gk vs Brunt

No

5.5

DM & obesity

Age, sex, MTX dose, alcohol, DM, and obesity.

NASH is an important cause of liver injury in patients on MTX.

Kent et al, 2004 [46]

Retrospect ive, hospital based

RA

USA

Not specifie d

48 1

n/a

n/a

4.8

DM, obesity , & HLD

Age, sex, duration of RA, duration of MTX treatment, DM, BMI, HLD, prior chronic viral hepatitis, folate supplement ation

Patients with obesity, HLD, and lack of folate supplement ation are at risk for liver injury defined as abnormal LE while on MTX treatment.

Aithal et. al., 2004 [28]

Retrospect ive: HospitalBased

Psorias is

UK

3206

66

Roeni gk vs Ishak vs Scheu er

Yes

5.4

DM & obesity

Age, sex, alcohol, DM, obesity, cumulative dose, weekly dose

Low dose MTX in patients without risk factors is safe, and risk of fibrosis starts after 4gm of cumulative dose

Berend s et. al., 2006 [31]

Retrospect ive: HospitalBased

Psorias is

Netherla nds

2113

12 5

Roeni gk

No

4.2

DM & obesity

Age, sex, duration of MTX, weekly dose, cumulative dose, DM, obesity,

Presence of obesity, and/or DM led to progression to a higher Roenigk score, at earlier

22

Rosenb erg et al 2007 [29]

Retrospect ive, Hospital based

Psorias is

Sweden

Specifie d for patient groups

71

Kleiner

No

Notspecifi ed

DM & obesity

alcohol use

cumulative MTX dosage

Age, sex, cumulative MTX, weekly dose, alcohol, DM, obesity, chronic viral hepatitis.

Patients with risk factors (alcohol, DM, obesity, and chronic viral hepatitis) are at higher risk of developing fibrosis on MTX therapy.

Key: MTX – methotrexate, RA – rheumatoid arthritis, PA – psoriatic arthritis, DM – diabetes mellitus, BMI – body mass index, HLD hyperlipidemia

Table 7. Risk factors for MTX-associated liver injury NAFLD/ Metabolic risk factors (see table 4) Alcohol Chronic liver disease, including genetic, viral, or autoimmune Lack of folate supplementation

23

Figure 1. Proposed Algorithm for Evaluation and Monitoring of Methotrexate Hepatotoxicity: Impact of NAFLD Assess for Risk Factors (See Table 7)

YES - refer to Hepatologist

NO

-

B

C

A Initiation tion of MTX monitor LE q4-6wks until stable dose and during changes in therapy - once stable dose reached, LE every 3months

Diagnosis of Other Ch Chronic Liver Di Diseases ni Li es Diagnosi NAFLD or Presence of Metabolic risk factors (Table 5) ors (Tab Recommend avoid MTX end av

therapy However, if MTX is required, to assess presence or absence of fibrosis prior to initiation (using non-invasive Non-invasive n-invasi evaluation or LE +/- liver evaluation biopsy, as in C) - Blood tests to assess Cumulative ve dose dos of 4gm - repeat assessment fibrosis (e.g. Fibrosure - evaluate for fibrosis with LSM +/- liver biopsy every 2gm. or Fibrotest) - NAFLD fibrosis Score or FIB-4 - LSM No fibrosis

-

Fibrosis Fibros Possible Fibrosis

Unlikely ly fibrosis

Continue inue therapy the Discontinue scontinu therapy - repeat LSM +/- liver biopsy every 2gm of therapy

No fibrosis Initiation of MTX - repeat LSM +/- liver biopsy every 2gm of therapy

Liver biopsy ver bi

Fibrosis LE – liver enzymes, MTX – methotrexate, LSM – liver stiffness measurement, FIB-4 – fibrosis-4 score

Avoid MTX therapy oid MT