A Survey on Methotrexate Prescribing and Monitoring Practices in Ireland

Background

Methotrexate, originally an anti-neoplastic agent, is now extensively used at lower doses in dermatology and rheumatology for chronic inflammatory conditions. While its safety is supported by routine blood monitoring, there remains variability in recommended monitoring frequency, folic acid supplementation, liver function testing and the role of specific biomarkers like Type III Procollagen Peptide (PIIINP).

Objectives

This study aimed to compare methotrexate prescribing and monitoring practices in Ireland with various national guidelines, including those from the European Medicines Agency (EMA), British Association of Dermatologists (BAD) and European Alliance of Associations for Rheumatology (EULAR). The goal was to document current practices among dermatologists and rheumatologists in Ireland to identify any discrepancies in methotrexate prescribing and monitoring.

Methods

An online survey was distributed to members of the Irish Association of Dermatologists (IAD) and the Irish Society of Rheumatology (ISR) in July 2024. The questionnaire covered pretreatment screening, blood monitoring practices, folic acid supplementation and adverse events. Data was finalised and analysed in September 2024.

Results

Of the 52 respondents, all conducted baseline full blood count (FBC), renal profile (RP) and liver function tests (LFTs). Dermatologists were significantly more likely to perform infectious disease screenings compared to rheumatologists (p < 0.05). When initiating methotrexate, only 17 practitioners (32.7%) employed a test dose of 2.5–5 mg weekly, with a statistically significant difference (p < 0.05) observed in the starting doses of methotrexate. All respondents prescribed folic acid supplementation, with a statistically significant (p < 0.05) noted in supplementation practices between the two specialties. Abnormal LFTs/PIIINP prompted hepatology referrals for 48%. Seven (13%) reported irreversible liver damage cases, and one (2%) death from pneumonia was noted.

Conclusions

This study highlights significant discrepancies in methotrexate prescribing and monitoring practices among Irish clinicians, similar to the various international guidelines. These variations underscore the need for updated, unified guidelines to ensure consistent and safe methotrexate use across the specialties.