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Methotrexate Monitoring — SCE Dermatology MCQ

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ModerateDermatopharmacologyMethotrexate MonitoringSCE Dermatology

A 45-year-old man with plaque psoriasis has been on Methotrexate for 8 years with good control. His cumulative dose is approaching 3.5 g. PIIINP has been consistently normal (<4.2 mcg/L) throughout. What is the implication of consistently normal PIIINP?

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Correct answer: B — Consistently normal PIIINP excludes significant hepatic fibrosis; liver biopsy can be avoided

The Manchester guidelines established that consistently normal serial PIIINP levels (<4.2 mcg/L) in patients on long-term Methotrexate have a very high negative predictive value for significant hepatic fibrosis. This means liver biopsy can be safely avoided when PIIINP monitoring shows no abnormalities. BAD guidelines adopted this approach, reducing the need for the invasive and potentially morbid liver biopsy that was previously recommended at cumulative doses of 1.5 g (AAD guidelines). PIIINP should be measured at baseline then every 2-3 months. Liver biopsy is indicated only when PIIINP is persistently elevated (>4.2 mcg/L on 3 occasions in 12 months or >8.0 mcg/L on 2 consecutive samples).

Reference: BAD 2016 Methotrexate Guidelines; Manchester PIIINP Protocol