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Original Investigation |

The Use of Transient Elastography and FibroTest for Monitoring Hepatotoxicity in Patients Receiving Methotrexate for Psoriasis

Maeve Lynch, MB, BCh, BAO, MRCPI1; Eleanor Higgins, MB, BCh, BAO, MRCPI1; P. Aiden McCormick, MD, FRCPI2; Brian Kirby, MB, FRCPI1; Niamh Nolan, MB, FRCPath3; Sarah Rogers, MD, FRCPI, MSc1; Aoife Lally, MD, FRCPI1; Akke Vellinga, MSc, PhD4; Haniza Omar, MB, BCh, BAO, MMed2; Paul Collins, MD, FRCPI, DCH1
[+] Author Affiliations
1The Charles Centre, Dermatology Department, St Vincent’s University Hospital, Dublin, Ireland
2Liver Unit, St Vincent’s University Hospital, Dublin, Ireland
3Histology Department, St Vincent’s University Hospital, Dublin, Ireland
4Department of General Practice, School of Medicine, National University of Ireland, Galway, Ireland
JAMA Dermatol. 2014;150(8):836-862. doi:10.1001/jamadermatol.2013.9336.
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Importance  There is a need for noninvasive tools to monitor hepatotoxicity in patients with psoriasis who are receiving methotrexate sodium.

Objective  To evaluate the use of transient elastography (TE) and FibroTest (FibroSURE in the United States), an indirect serum marker of fibrosis, in this population.

Design, Setting, and Participants  Patients receiving methotrexate therapy for psoriasis between January 2008 and September 2009 were recruited from a dermatology outpatient department. Transient elastography and FibroTest were performed, and patients with abnormal results were considered for liver biopsy. Serial procollagen III peptide (PIIINP) results were recorded.

Interventions  Transient elastography uses pulse-echo ultrasonography to measure liver stiffness, and this result is an indirect measure of hepatic fibrosis. FibroTest is an indirect serum marker of hepatic fibrosis.

Main Outcomes and Measures  Procollagen III peptide, TE, and FibroTest results, as well as the need for liver biopsy in this cohort.

Results  Seventy-seven patients (41 male [53%]) were included. Fifty (65%) patients had a valid TE assessment, and 9 (18%) had an abnormal result (range, 7.1-11.3 kPa). Being overweight or obese increased the possibility of obtaining an invalid TE result significantly (P = .01). On univariate analysis body mass index (r = 0.40, P = .005) and age (r = 0.52, P = .005) were correlated with abnormal TE results. Seventy-one patients received a FibroTest and 11 of 70 analyzed (16%) had an abnormal result (METAVIR score >F1). Age (r = 0.31, P = .009), cumulative methotrexate dose (r = 0.31, P = .01), and duration of methotrexate therapy (r = 0.36, P = .002) were correlated with abnormal FibroTest results. There was no correlation between PIIINP levels and TE results or between PIIINP levels and FibroTest results. Steatosis was demonstrated in all 5 patients who received liver biopsies during the study. Two patients had hepatic fibrosis, with 1 showing a sinusoidal pattern of fibrosis attributed to steatohepatitis.

Conclusions and Relevance  Transient elastography and FibroTest are effective noninvasive tools for monitoring hepatotoxicity in patients receiving methotrexate for psoriasis. We propose that the need for liver biopsy could be reduced if abnormalities in at least 2 tests (serial PIIINP, TE, or FibroTest) are required before biopsy is considered. This strategy should be evaluated in prospective studies.

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Transient Elastography and FibroTest Trial Flow Diagram

Recruitment and enrollment of patients for transient elastography and FibroTest. PIIINP indicates procollagen III peptide.

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