Canadian recommendations for use of methotrexate in patients with rheumatoid arthritis.
OBJECTIVE
To develop recommendations for the use of methotrexate (MTX) in patients with rheumatoid arthritis.


METHODS
Canadian rheumatologists who participated in the international 3e Initiative in Rheumatology (evidence, expertise, exchange) in 2007-2008 formulated 5 unique Canadian questions. A bibliographic team systematically reviewed the relevant literature on these 5 topics. An expert committee consisting of 26 rheumatologists from across Canada was convened, and a set of recommendations was proposed based on the results of systematic reviews combined with expert opinions using a nominal group consensus process.


RESULTS
The 5 questions addressed drug interactions, predictors of response, strategies to reduce non-serious side effects, variables to assess clinical response, and incorporating patient preference into decision-making. The systematic review retrieved 93 pertinent articles; this evidence was presented to the expert committee during the interactive workshop. After extensive discussion and voting, a total of 9 recommendations were formulated: 2 on drug interactions, 1 on predictors of response, 2 on strategies to reduce non-serious side effects, 3 on variables to assess clinical response, and 1 on incorporating patient preferences into decision-making. The level of evidence and the strength of recommendations are reported. Agreement among panelists ranged from 85% to 100%.


CONCLUSIONS
Nine recommendations pertaining to the use of MTX in daily practice were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement.
Department of Medicine, University of Toronto, Toronto, ON, Canada.
Wanruchada
W
Katchamart
Josiane
J
Bourré-Tessier
Timea
T
Donka
Julie
J
Drouin
Gina
G
Rohekar
Vivian P
VP
Bykerk
Boulos
B
Haraoui
Sharon
S
Leclerq
Dianne P
DP
Mosher
Janet E
JE
Pope
Kam
K
Shojania
John
J
Thomson
J Carter
JC
Thorne
Claire
C
Bombardier
D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D002170:Canada; D019317:Evidence-Based Medicine; D006402:Hematologic Diseases / Q000139:chemically induced; D006801:Humans; D008099:Liver / Q000187:drug effects / Q000201:enzymology; D008727:Methotrexate / Q000009:adverse effects / Q000627:therapeutic use*; D057240:Patient Preference; D017410:Practice Guidelines as Topic; D012219:Rheumatology / Q000592:standards
D018501:Antirheumatic Agents; D008727:Methotrexate