Why Are We Still Undergoing Liver
She Had a Disastrous Liver Biopsy
Ed: With respect to your response to Sharon S. in the above-referenced
correspondence; I’ve been on MTX for 11 years non-stop for an accumulated
dosage that’s well over 5 grams. Never had liver biopsy. Have always had
blood work every other month with normal liver function results. My
Consensus is that
if your liver function tests are normal there’s no reason to do a
biopsy. There is a significant correlation between hepatic aspartate
aminotransferase (AST) and progression of histologic deterioration in
patients with RA receiving chronic weekly MTX.
Some believe a
biopsy is in order when MTX reaches cum 5.0 grams [no longer 1.5g].
Some believe that
since psoriasis patients often insist on remaining on MTX, there’s
probably little reason to have the biopsy in the first place.
http://www.ccjm.org/PDFFILES/Siegel3_05.pdf [See page 7 of 13]
Adobe Acrobat Reader)
My guess is that the guidelines for biopsy at 1.5g of MTX are still in
place due to lack of additional evidence to support not having a biopsy.
This type of evidence, if I understand correctly, would need to come from
those of us that have accumulated <5.0 grams and have consistently normal
blood results. Who of us wants a biopsy when all else is normal just to
formally change liver biopsy guidelines?
Perhaps you want to edit your message. Thanks. -Lynn
Ed's Response: Thanks for this, Lynn. Excellent information that I'll post
in January. My only quibble is your first bullet: "Consensus is that if
your liver function tests are normal there's no reason to do a biopsy." I
wouldn't call that a "consensus" so long as there are many derms still
prescribing liver biopsies based on cumulative dose of 1.5 mgs or greater.
I would call that an "informed argument" that is gaining favor.
I think our healthcare culture often moves so (seemingly) slow because
anything less than a formal agreement about how to do things leaves wide
open spaces for litigation. In such an environment medicine must progress
"by resolution" rather than "by evolution." I overstate, but not by much!
Thanks for sharing your research. It will show up at FlakeHQ, now,
whenever anyone searches on "liver biopsy." -Ed
Lynn Responds: How do you know there are many still prescribing liver
biopsies on the basis of cum dose? It may be in the guidelines, but how
many physicians are actually following them?
Actually it was a consensus of a group of rheumatologists at a conference,
as reported to me by my own rheumatologist, and subsequently reported to
me from patients of other rheumatologists.
Granted, studies of MTX hepatotoxicity cover a longer period of time for
dermatologists as compared to rheumatologists; the older dermatology
patient histories reflect much higher dose MTX than are currently
prescribed [which arguably create an unfair comparison to the
rheumatologists’ data]. The dermatologists’ data supporting liver biopsies
also include blood studies at longer intervals than rheumatologists order.
Consider the following:
Annals of the Rheumatic Diseases 2005;64:ii91-ii92
©2005 by BMJ Publishing Group Ltd & European League Against Rheumatism
Psoriatic arthritis and psoriasis: treatment
Discussion: Treatment of psoriatic arthritis and psoriasis
And this pdf link:
http://www.ccjm.org/PDFFILES/Siegel3_05.pdf (search for
Adobe Acrobat Reader).
There are countless arguments against the biopsy. If dermatologists are
indeed prescribing them in accordance to their seemingly outdated
guidelines, it would appear that there is a dire need for revision. -Lynn
Ed's Response: How do you know there aren't? ...
I'm sure there may be some derms who see things the way more liberated
rheumies do, but I doubt there's been a poll taken among licensed U.S.
derms to determine if they are still following guidelines (perhaps
antiquated) regarding methotrexate therapy for P. The article you cite
from the Annals of the Rheumatic Diseases seems to substantiate my
argument. I.e., "Menter : The guidelines about monitoring psoriasis
patients on methotrexate therapy are quite clear, recently updated in
1998, and based on 30+ years of experience with use of the drug, unlike
rheumatology guidelines, which are based on a shorter experience and are
quite different. Dermatologists take these guidelines seriously, given the
experience on which they are based."
While I certainly wish MTX for P could be administered without
liver biopsies unless blood work suggested them, I could not say to any
flaker, "Find a doctor who will prescribe MTX but won't make you have a
liver biopsy based on accumulated dosage." On the contrary, if I receive
email from folks in the U.S. saying they've never had a liver biopsy and
they've been on MTX for several years, three questions will come to mind:
(1) Was the dose so low they've probably not accumulated 1500 mgs? (2)
Does the dermatologist forget or overlook the protocol? Or (3) Is the
dermatologist enlightened, keeping close tabs on blood work, and not
worried about liability should something disastrous happen?
As the argument for cumulative-dose-guided liver biopsies intensifies, I
hope the U.S. dermatology authorities will reconsider, and I hope the
evidence presented to them will suggest a change in their recommended
protocol is in order. If they're really not necessary, anyone would like
to avoid a liver biopsy. -Ed
Lynn Responds: The only thing I can say to that is that dermatological
doses are certainly no higher than rheumatological doses. Further, if
there’s any enlightening to be done, it’s with regard to dermatologists,
who need to review appropriate data and update their guidelines. And as
for this criteria of cumulative doses — it ought to be thrown out
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