William H. Vaughn

Supplementation with folic acid during methotrexate therapy for rheumatoid arthritis. A double-blind, placebo-controlled trial.

The folic acid antagonist methotrexate (n-10-methyl-aminopterin) is useful in low doses (2.5 to 20 mg/wk) for treating chronic inflammatory diseases [1-7]. Many trials have established the efficacy of methotrexate in rheumatoid arthritis [7-13]. Compared with other disease-modifying drugs, methotrexate has the highest probability of drug continuation at 10 years. Dose response-related toxic effects have been reported in 30% to 90% of patients given methotrexate [13]. Toxic effects include gastrointestinal intolerance, hematologic abnormalities, alopecia, hepatotoxicity, and pulmonary toxicity [14-22]. Some side effects of methotrexate administration, such as gastrointestinal intolerance, mimic complicated folate deficiency [23]. Folate deficiency occurs frequently in patients with rheumatoid arthritis; further, folate stores are decreased in patients with rheumatoid arthritis who take methotrexate, suggesting that impaired folate status is related to toxicity [24-26]. Folic acid supplementation has been reported anecdotally to lessen toxicity in patients receiving methotrexate treatment [27, 28]. In a 6-month, double-blind, placebo-controlled trial, 7 mg of folic acid weekly (1 mg/d or 2265 nmol/d) decreased methotrexate toxicity without affecting efficacy [29]. This was confirmed by Stewart and colleagues [30] in a retrospective chart review. Folinic acid (leucovorin, citrovorum factor) is a one-carbon-substituted, fully reduced folate that has also been administered during methotrexate therapy [31-36]. Low doses of the vitamin (1 to 7 mg/wk) have decreased methotrexate toxicity [35, 36]. Higher doses negate efficacy and lessen toxicity [31, 32]. Thus, the folinic acid dose may critically affect the efficacy of methotrexate therapy. The influence of the folic acid dose on methotrexate toxicity and efficacy remains controversial, and the effects of different doses of folic acid are not known [37, 38]. Some investigators argue that if toxic effects occur, the most rational approach is to reduce the dose of methotrexate rather than to provide folic acid supplements [37]. We designed a larger and longer study to evaluate different doses of folic acid, assuming that toxicity could be reduced without changing the efficacy of methotrexate. Methods Participants Patients aged 19 to 78 years who fulfilled the American College of Rheumatologys revised criteria for rheumatoid arthritis consented to participate in the trial [39]. Enrollment criteria included rheumatoid arthritis diagnosed more than 6 months previously, onset after the age of 16 years, and at least three of the following signs or symptoms: 3 or more swollen joints, 6 or more tender joints, at least 45 minutes of morning stiffness, and a Westergren erythrocyte sedimentation rate 28 mm/h. Referring rheumatologists and the principal investigator did the screening. Exclusion criteria included serious concomitant medical illnesses, liver enzyme levels twice the upper limit of normal, leukocyte counts less than 3.5 109/L or platelet counts less than 150 109/L, and use of methotrexate within the past 6 months. Gold salts were stopped for at least 10 days before the trial. This short washout period mirrors actual rheumatology practice. Patients remained under the care of their rheumatologists, abstained from alcohol use, did not become pregnant, and received stable doses of aspirin and nonsteroidal anti-inflammatory drugs. If prednisone was taken at entry, the dose could not exceed 10 mg/d. Hydroxychloroquine therapy was allowed during the study. Study Design Figure 1 shows the trial design. To maintain the double-blind status of the trial, the statistician carried out the randomization using a computer program in which the algorithm was transparent and a coded vial number represented the treatment assignment. Patients were assigned to treatment groups by a sequential treatment assignment process designed to balance the sample with respect to baseline features, including age, sex, folate-containing vitamin use, rheumatoid factor status, and prednisone use [40]. Patients agreed to discontinue therapy with folate-containing vitamins during the trial. Rheumatoid factor was considered positive if the level was more than 30 IU/mL or if the titer was more than 1:160. Patients received either visually identical placebo or 5 mg (low-dose folic acid group) or 27.5 mg folic acid (high-dose folic acid group) each week, prepared by the Hospital Investigational Drug Service. Spectrophotometric analysis indicated that the mean SD folic acid content was 1 0.15 mg (2.3 0.3 mol) and 5.5 0.3 mg (12.5 0.7 mol) per capsule in the low-dose and high-dose folic acid groups, respectively. Lederle Laboratories provided the methotrexate (Rheumatrex; Pearl River, New York), which was started in a median oral dose of 16.5 mol (7.5 mg) per week and increased in 5.5-mol (2.5 mg) increments at the rheumatologists discretion. Methotrexate was taken either in an undivided or a divided dose (that is, every 12 hours for three doses). The methotrexate dosing regimens were identical among the study groups. Folic acid supplements were given 5 days per week when methotrexate was not ingested. Compliance with the regimen was reinforced using a digital reminder cap (Counter Cap; Senetics, Boulder, Colorado). All participants and investigators were blinded to vitamin capsule content until the study was complete. Figure 1. Study design for the double-blind, placebo-controlled trial. Clinical Assessment Patients were evaluated immediately before methotrexate initiation at a mean of 13, 26, 39, and 53 weeks (Figure 1). Each patient was assessed by the same physician-nutritionist (SLM). Two research assistants (JSA or WHV) did the joint evaluations. In most cases, patients were examined by the same observer throughout the study. The joint counts for tenderness and swelling were not significantly different between the two observers (P = 0.6 for tenderness; P = 0.9 for swelling). The following variables were evaluated at each visit: 1) number of the 58 diarthrodial joints with swelling; 2) number of the 60 joints with tenderness on pressure or with pain on passive motion (or both); 3) joint swelling and tenderness indices, expressed as a sum, with each joint graded for swelling as 0 (none), 1 (mild), 2 (moderate), or 3 [severe]; 4) mean grip strength (three measurements) for both hands expressed in mm Hg; 5) duration of morning stiffness expressed in hours; 6) patients and physicians global assessments of disease activity graded as 0 (asymptomatic), 1 (mild), 2 (moderate), 3 (severe), or 4 (very severe); 7) current medications and doses; 8) a 1-day dietary recall using the Minnesota Nutrition Data System software, Food Database version 6A, Nutrient Database version F21 [41]; 9) eight activities of daily living assessed and averaged at baseline and at 12 months using the modified Health Assessment Questionnaire and scored on a scale of 1 (no difficulty) to 4 (unable to perform) [42]; and 10) presence, duration, intensity, and severity of toxic effects at every follow-up visit and every 3 weeks by telephone interview (done by SLM). Laboratory Assessments At the initial visit, complete blood cell count, Westergren erythrocyte sedimentation rate, liver enzyme (aspartate amino transferase and alkaline phosphatase), rheumatoid factor by nephelometry, and serum creatinine values were obtained. The complete blood cell count, creatinine, and liver function tests were repeated at all visits. If laboratory values were obtained more frequently than stipulated in the protocol, they were recorded and became part of the toxicity score. Blood for plasma and erythrocyte folate levels, using a methotrexate-resistant Lactobacillus casei microbiological assay, was drawn at all visits [43]. At baseline, blood was drawn for a vitamin panel (plasma and erythrocyte folate, vitamins B12, A, C, and E, carotene, riboflavin, thiamin, pyridoxine) [44-51]. If patients had abnormal values for any of the vitamins, other than folate, the abnormality was treated with single vitamin supplements. Radiographic Assessment Hand and wrist radiographs taken within 6 months of entering the trial were assessed by one of the rheumatologists (GSA) without knowledge of study status. Joint erosions and space narrowing were determined by the modified method of Sharp [52]. Results were expressed as the mean raw scores for joint erosion and joint space narrowing. Toxicity: Frequency and Severity Toxic effects and discontinuation of therapy with study medications due to toxicity were considered primary outcomes. We determined a toxicity score, modified from the one previously used, for each patient at each visit or until methotrexate therapy was discontinued [29] (Appendix). Efficacy We determined patient response to treatment using a modification of the criteria used in our previous folic acid supplementation trial and by others [8, 29, 53]. We defined marked improvement in the joint swelling index and the joint tenderness and pain index as a net decrease of 50% or more in value at any follow-up visit compared with visit 1. We defined moderate improvement as a 30% to 49% net decrease in the index, and no change as the index value remaining within 30% of the original value. We defined worsening as an increase in the index value of 30% or more. We examined the effects of folic acid supplementation on changes in physician and patient global assessments, grip strength, morning stiffness, erythrocyte sedimentation rate, findings of the modified Health Assessment Questionnaire, complete blood cell counts, blood folate levels, and dietary folate and vitamin B12 intake. Table 1. Demographic and Selected Clinical Characteristics of 79 Patients with Rheumatoid Arthritis* Statistical Analysis Sample Size and Analysis In our previous study, the mean toxicity scores for patients receiving low-dose folic acid and placebo recipients were 0.21 and 1.06, respectively, for

Modification of a high-performance liquid chromatographic method for assay of homocysteine in human plasma.

A modification of a previously published method for analysis of total homocysteine in human serum is presented. The modification was implemented to allow use of a different derivatizing agent (i.e., 7-fluorobenzo-2-oxa-1,3-diazole-4-sulfonamide) which reacts much faster than the original derivatizing reagent and at a lower temperature. Shorter reaction time and lower temperature lead to less destruction of some biological thiols. In order to retain an isocratic mobile phase with the new derivatizing agent, a different concentration of acetonitrile was found that affords a 7-8 min retention time.

The use of an enteral expert system in the prescription of enteral formulas in a university hospital

A personal computer-based expert system has been developed for the prescription of enteral formulas based on patient-need characteristics. Two hundred twelve inpatients in a university hospital setting were prospectively evaluated to compare the identity and cost of the enteral formula prescribed by the expert system with the identity and cost of the enteral formula prescribed by the ward team. Two hundred seven patients had complete data to allow analysis. There was a mean cost savings (+/-SD) of

The effect of folic acid supplementation on the toxicity of low-dose methotrexate in patients with rheumatoid arthritis.

1.18 +/- 7.69/d for each patient using the expert system compared with the MD-prescribed formula (P = 0.023). We project that the use of this program would save

Effects of Folate Deficiency and Supplementation on Methylnitrosourea-Induced Rat Mammary Tumors

27,564/y in our hospital (an average of 23,360 patient/days of enteral feeding per year). We conclude that the use of an expert system can be cost-effective in the prescription of enteral formulas for hospitalized patients.