Short methotrexate stop is safe in patients with RA

Temporary cessation of methotrexate for 2 weeks is safe and has no effect on rheumatoid arthritis (RA) disease activity. Discontinuing methotrexate for 4 weeks is linked to a temporary increase in disease activity without affecting long-term health outcomes.

“In special circumstances, including infections, vaccinations, or major surgeries, the use of methotrexate should be minimised to restore the treatment-associated immune suppression. However, the effect of short-term methotrexate cessation on disease activity remains unknown.

“We previously reported two randomised control trials showing that short-term methotrexate discontinuation can significantly improve immunogenicity after seasonal influenza vaccination in patients with RA,” said Dr Min Jung Kim (Seoul National University Hospital, South Korea). In the presented study, post-hoc analysis compared the effects of methotrexate discontinuation for 2 or 4 weeks on vaccine response to seasonal influenza vaccination in RA patients. In the 2-week cessation study, 159 patients continued methotrexate and 161 patients discontinued it for 2 weeks after a seasonal quadrivalent influenza vaccine. In the 4-week cessation study, 54 patients continued methotrexate and 44 patients discontinued it for 4 weeks before vaccination with a trivalent seasonal influenza vaccine. Disease activity, change in DAS28, DAS28 flare rate, and flare-free survival were compared between patients of both groups. A flare was defined as an increase in DAS28 >1.2 (or >0.6 if baseline DAS28 was ≥3.2).

The results showed that a 2-week methotrexate cessation was not linked to any significant change in disease activity. In the 4-week discontinuation group, the mean DAS28 increased at 4 weeks after methotrexate discontinuation by 0.38, and improved to baseline level after reintroduction of methotrexate. Mean DAS28 remained stable over time in patients who continued methotrexate. Temporary discontinuation showed no significant effect on flare-free survival throughout the duration period of 20 weeks (P=0.142), although, in the 4-week cessation study, numerically more patients in the methotrexate-hold group experienced a flare, compared with those in the methotrexate-continue group(20.5% vs 7.4%, P=0.058). It is worth pointing out that the adjuvant properties of the vaccine may have been a factor in flares in the post vaccination setting which was not addressed in this study.

1. Jung Kim Min, et al. Abstract OP0027. EULAR 2019

Posted on 4 September 201917 March 2021