title: Hepatotoxicity caused by methotrexate therapy in children with inflammatory bowel disease: a systematic review and meta-analysis.
abstract: BACKGROUND
  Methotrexate (MTX) is an immunomodulator used in pediatric inflammatory bowel disease (IBD) maintenance regimens. However, MTX use is associated with liver toxicity. We aimed to systematically review and meta-analyze the incidence of hepatotoxicity with MTX use among children with IBD.
  
  
  METHODS
  We searched MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from 1946 to April 2013 for cohort studies and collected information about the study design, IBD treatment results, and hepatotoxicity. Pooled proportions of toxicity with 95% confidence interval (CI) were estimated using a random-effects model.
  
  
  RESULTS
  Twelve high-quality studies were included in this review. Fifty-seven of 457 patients treated with MTX developed varied degrees of abnormal liver biochemistry. The pooled proportion of patients with abnormal liver biochemistry was 10.2% (95% CI 5.4%-18.5%) across all studies included in the meta-analysis. Due to hepatotoxicity, dose reductions were required in 6.4% (95% CI 4.3%-9.5%), whereas 4.5% (95% CI 2.8%-7.2%) of patients required discontinuation.
  
  
  CONCLUSIONS
  Hepatotoxicity after the use of MTX among IBD patients was a relatively common event. Monitoring for hepatotoxicity is strongly recommended, as discontinuation of MTX may be necessary in a significant proportion of children.
authors.affiliation: 1Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; 2Neonatal Intensive Care Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; 3Department of Clinical Epidemiology and Biostatistics, McMaster University, Toronto, ON, Canada; and 4Division of Rheumatology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
authors.forename: Pamela L
authors.initials: PL
authors.lastname: Valentino
authors.forename: Peter C
authors.initials: PC
authors.lastname: Church
authors.forename: Prakeshkumar S
authors.initials: PS
authors.lastname: Shah
authors.forename: Joseph
authors.initials: J
authors.lastname: Beyene
authors.forename: Anne M
authors.initials: AM
authors.lastname: Griffiths
authors.forename: Brian M
authors.initials: BM
authors.lastname: Feldman
authors.forename: Binita M
authors.initials: BM
authors.lastname: Kamath
mesh_terms: D006801:Humans; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology / Q000473:pathology; D007166:Immunosuppressive Agents / Q000009:adverse effects; D015212:Inflammatory Bowel Diseases / Q000150:complications / Q000188:drug therapy; D008099:Liver / Q000187:drug effects; D008727:Methotrexate / Q000009:adverse effects; D011379:Prognosis
chemical_list: D007166:Immunosuppressive Agents; D008727:Methotrexate