title: The Australasian Psoriasis Collaboration view on methotrexate for psoriasis in the Australasian setting.
abstract: The Australasian Psoriasis Collaboration reviewed methotrexate (MTX) in the management of psoriasis in the Australian and New Zealand setting. The following comments are based on expert opinion and a literature review. Low-dose MTX (< 0.4 mg/kg per week) has a slow onset of action and has moderate to good efficacy, together with an acceptable safety profile. The mechanism of action is anti-inflammatory, rather than immunosuppressive. For pretreatment, consider testing full blood count (FBC), liver and renal function, non-fasting lipids, hepatitis serology, HbA1c and glucose. Body mass index and abdominal circumference should also be measured. Optional investigations in at-risk groups include an HIV test, a QuantiFERON-TB Gold test and a chest X-ray. In patients without complications, repeat the FBC at 2-4 weeks, then every 3-6 months and the liver/renal function test at 3 months and then every 6 months. There is little evidence that a MTX test dose is of value. Low-dose MTX rarely causes clinically significant hepatotoxicity in psoriasis. Most treatment-emergent liver toxicity is related to underlying metabolic syndrome and non-alcoholic fatty liver disease or non-alcoholic steatohepatitis. Alcohol itself is not contraindicated, but should be limited to < 20 gm/day. [Correction added on 6 January 2017, after first online publication: '20 mg/day' has been corrected to '20 gm/day'.] Although MTX is a potential teratogen post-conception, there is little evidence for this pre-conception. MTX does not affect the quality of sperm. There is no evidence that MTX reduces healing, so there is no specific need to stop MTX peri-surgery. MTX may be used in combination with cyclosporine, acitretin, prednisone and anti-tumour necrosis factor biologics.
authors.affiliation: Department of Dermatology, Waikato Clinical Campus, Auckland Medical School, Hamilton, New Zealand.
authors.forename: Marius
authors.initials: M
authors.lastname: Rademaker
authors.affiliation: Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia.|Department of Medicine, UNSW, Sydney, New South Wales, Australia.
authors.forename: Monisha
authors.initials: M
authors.lastname: Gupta
authors.affiliation: Dermatology, Specialist Connect, Woolloongabba, Queensland, Australia.
authors.forename: Megan
authors.initials: M
authors.lastname: Andrews
authors.affiliation: Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia.|Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia.
authors.forename: Katherine
authors.initials: K
authors.lastname: Armour
authors.affiliation: Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia.|Department of Medicine (Dermatology), The University of Melbourne, Melbourne, Victoria, Australia.|Department of Dermatology, St Vincent's Hospital, Melbourne, Victoria, Australia.
authors.forename: Chris
authors.initials: C
authors.lastname: Baker
authors.affiliation: Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia.|Department of Medicine (Dermatology), The University of Melbourne, Melbourne, Victoria, Australia.|Department of Dermatology, St Vincent's Hospital, Melbourne, Victoria, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Foley
authors.affiliation: Department of Dermatology, University of Western Australia, Perth, Western Australia, Australia.
authors.forename: Kurt
authors.initials: K
authors.lastname: Gebauer
authors.affiliation: Department of Medicine, University of Sydney, Sydney, New South Wales, Australia.|Department of Medicine, Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, Sydney, New South Wales, Australia.
authors.forename: Jacob
authors.initials: J
authors.lastname: George
authors.affiliation: Department of Dermatology, Canberra Hospital, Canberra, Australian Capital Territory, Australia.|Department of Dermatology, Australian National University, Canberra, Australian Capital Territory, Australia.
authors.forename: Diana
authors.initials: D
authors.lastname: Rubel
authors.affiliation: Department of Medicine, UNSW, Sydney, New South Wales, Australia.|Dermatology, Holdsworth House Medical Practice, Sydney, New South Wales, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Sullivan
mesh_terms: D000428:Alcohol Drinking; D001315:Australia; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology*; D003879:Dermatologic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D016903:Drug Monitoring; D004359:Drug Therapy, Combination; D006801:Humans; D008107:Liver Diseases / Q000150:complications; D008727:Methotrexate / Q000494:pharmacology / Q000627:therapeutic use*; D009520:New Zealand; D011565:Psoriasis / Q000150:complications / Q000188:drug therapy*; D060728:Reproductive Health
chemical_list: D003879:Dermatologic Agents; D008727:Methotrexate
keywords: expert opinion; liver toxicity; methotrexate; monitoring; psoriasis