Latest Guidelines for Methotrexate use in Juvenile Idiopathic Arthritis

A Methotrexate Advice and Recommendations on Juvenile Idiopathic Arthritis (MARAJIA) Expert Meeting was held to develop evidence-based recommendations for the use of methotrexate (MTX).MTX is the most commonly prescribed non-biological, disease-modifying antirheumatic drug for the treatment of juvenile idiopathic arthritis (JIA). The recommendations appeared in the Pediatric Rheumatology journal.

The preliminary executive committee consisting of Giovanna Ferrara et al. identified a total of 9 key clinical issues according to the population, intervention, comparator, outcome (PICO) approach, and performed an evidence-based, systematic, literature review. During the subsequent Expert Meeting, the relevant evidence was assessed and graded, and 10 recommendations were made.

Read Also: Latest recommendations for JIA associated uveitis

Key Recommendations:

• MTX is recommended as the first-line treatment in oligoarthritis that persists despite nonsteroidal anti-inflammatory drugs (NSAIDs) and intraarticular steroid (IAS) therapy, and in polyarticular disease. MTX is also recommended in systemic arthritis with predominant joint inflammation, without active systemic features.


• Clinical and laboratory monitoring of MTX toxicity is recommended every 4-8 weeks initially, and then every 12-16 weeks, unless risk factors are present.


• The dose of methotrexate in juvenile idiopathic arthritis: 10-15 mg/m2/week is recommended. Further increases in MTX dosage have not been associated with the additional therapeutic benefit.


• MTX may be given orally or subcutaneously once a week. If high doses (15 mg/m2/week) are requested, the subcutaneous route is preferable due to increased bioavailability.


• Regarding tapering and discontinuation of methotrexate in juvenile idiopathic arthritis -MTX could be discontinued after 6 months of stable remission.


• Folic or folinic acid supplementation is recommended to prevent MTX side effects. The advised dose is approximately one-third of the MTX dose, at least 24 hours after the weekly dose of MTX for folinic acid; for folic acid 1 mg/day skipping the day when MTX is administered.


• MTX is recommended for the treatment of JIA-related uveitis refractory to topical treatment.


• The combination of MTX with a TNF-α inhibitor is recommended in patients who had an inadequate clinical response to MTX alone.


• No recommendation is made regarding the use of biomarkers in current clinical practice.


• Vaccination with non-live vaccines is not contraindicated during MTX treatment.

According to the authors, these consensus recommendations provide balanced and evidence-based recommendations which will guide the physicians and healthcare professionals to have an effective clinical management of patients with JIA. Juvenile idiopathic arthritis is the most common type of arthritis in children aged below 16. Juvenile idiopathic arthritis can cause persistent joint pain, swelling, and stiffness.

For reference log on to https://doi.org/10.1186/s12969-018-0255-8