[Portuguese recommendations for the use of methotrexate in the treatment of rheumatoid arthritis].
OBJECTIVE
To develop Portuguese evidence-based recommendations for the use of methotrexate (MTX) in daily clinical practice in rheumatic disorders.


METHODS
The Portuguese project was integrated in the multinational 3E Initiative (Evidence, Expertise, Exchange) 2007-2008 where a total of 751 rheumatologists from 17 countries have participated. Ten clinical questions concerning the use of MTX in rheumatic diseases were formulated and the Portuguese group added three more questions. A systematic literature search in Medline, Embase, Cochrane Library and 2005-2007 ACR/EULAR meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford Levels of Evidence. In Portugal, a national meeting was held in Obidos on February 15th and 16th, 2008, involving 50 rheumatologists who discussed and voted by Dephi method the recommendations. Finally, the agreement among the rheumatologists and the potential impact on their clinical practice was assessed.


RESULTS
Thirteen national key recommendations on the use of MTX were formulated: work-up before starting MTX, optimal dosage and route of administration, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy, management in the peri-operative period, during infections, before/during pregnancy and after clinical remission, screening and treatment of tuberculosis and the role of MTX as a steroid-sparing agent in rheumatic diseases.


CONCLUSIONS
The Portuguese recommendations for the use of MTX in daily clinical practice were developed, which are evidence-based and supported by a panel of 50 rheumatologists, enhancing their validity and practical use. This project was integrated in a multinational initiative that led to the recent publication of ten multinational recommendations which differ from ours in some specific aspects.
Canhão
Helena
H
Serviço de Reumatologia, Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, Lisboa. helenacanhao@netcabo.pt
Santos
Maria José
MJ
Costa
Lúcia
L
Bogas
Mónica
M
Mourão
Ana Filipa
AF
Machado
Pedro
P
Fonseca
João Eurico
JE
Silva
José António
JA
D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D006801:Humans; D008727:Methotrexate / Q000627:therapeutic use*; D011174:Portugal
D018501:Antirheumatic Agents; D008727:Methotrexate