In patients on methotrexate, noninvasive tests might help avoid liver biopsy
In patients on methotrexate, noninvasive tests might help avoid liver biopsy
By David Douglas
NEW YORK (Reuters Health) - Noninvasive testing may be
useful for spotting potential hepatotoxicity and confirming the
need for liver biopsy in psoriasis patients on methotrexate
sodium, according to Irish researchers who say more studies are
needed.
Combining the use of transient elastography (TE) and
FibroTest (FibroSURE in the U.S.) with serial procollagen III
peptide level measurements reduced the need for liver biopsy in
their study, Dr. Maeve Lynch told Reuters Health by email.
In a June 25th online paper in JAMA Dermatology, Dr. Lynch
of St Vincent's University Hospital, Dublin and colleagues note
that long-term methotrexate monotherapy is often used to manage
severe psoriasis. Liver fibrosis can be a side effect.
To assess the potential for noninvasive testing to help
avoid biopsies, the team studied 77 patients. Those with
abnormal results on TE and FibroTest were considered for liver
biopsy. Serial procollagen III peptide (PIIINP) results were
also recorded.
Fifty (65%) patients had a valid TE assessment, and nine
(18%) had an abnormal result. Seventy-one patients got a
FibroTest, and 11 of 70 analyzed (16%) had an abnormal result.
There was no correlation between PIIINP levels and TE or
Fibrotest results. In fact, liver biopsy was considered for 10
patients based on persistently abnormal PIIINP results before TE
or FibroTest was performed.
Five of these patients went on to have liver biopsies and
liver fibrosis was observed in two. Based on subsequently normal
TE or FibroTest results within the reference range, say the
investigators, three of the liver biopsies could have been
avoided.
Two of the 5 patients who had biopsies continued receiving
methotrexate, and three, including the two with fibrosis,
received alternative systemic or biologic therapies.
The researchers concede that the study had a number of
limitations. Only a small group was analyzed and there was
missing data. Not all patients were evaluated with PIIINP levels
or FibroTest. There was also an interval between the TE and
FibroTest assessments.
They call for larger prospective studies but conclude that
"the need for liver biopsy could be reduced if abnormalities in
at least two tests (serial PIIINP, TE, or FibroTest) are
required before biopsy is considered."
Dr. Bruce E. Strober, author of an accompanying editorial,
has some caveats. He points out that although attractive in its
simplicity, FibroTest has low sensitivity and it can only be
perform by validated laboratories.
Dr. Strober, of the University of Connecticut Health Center,
Farmington adds that "obesity, a common feature of patients with
psoriasis, often renders TE either unreliable or impossible.
Furthermore, widespread availability of TE is limited." As a
sole test, PIIINP is inadequate for many patients because it
lacks sensitivity and has limited worldwide availability.
"Concordant with most other medical specialties," continues
Dr. Strober, "dermatology should abandon the liver biopsy.
"Currently available noninvasive measures," he concludes,
"need to be used in combination and studied as such in large,
prospective, well-controlled studies."
SOURCE: http://bit.ly/1mNUrkH
JAMA Dermatol 2014.
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